Mr. G. had been doing poorly all day.
The surgery service I was attached to had been called to see him early in the morning for abdominal pain. He hadn’t looked good then, but he wasn’t bad enough to operate: pale and breathing hard, yes, but not the right kind of pain, not the right tenderness.
A CT scan later in the day showed that his spleen was bleeding, and that blood was accumulating in his abdomen and pelvis. You could see it dripping down. The blood was irritating his organs and the lining around them, causing pain.
About 2 p.m. that day, the last day of my surgery rotation in my fourth year of medical school, the surgeons decided to operate. Mr. G. had continued to lose blood from his spleen, and when they pressed down on his stomach, it hurt, but it hurt more when they let go - a sign of spreading inflammation.
There is nothing in this world like a surgery. One minute you are talking to a man, and 45 minutes later you are up to your elbows in his body, watching his diaphragm beat with the force of his heart, watching his intestines pulse, or seeing the pattern of black on the surface of his lungs from inhaling city pollutions for 50 years.
At 3:30 p.m., while the anesthesiologist and nurses were preparing the patient, I was standing in the hallway drinking coffee with the two surgeons, waiting.
They were getting jumpy. Something was growing in them, an energy, an agitation that I have rarely seen, like cops jumping out of a cruiser at the scene of an arrest, or cats twitching while watching birds.
A few minutes later we started. The patient was already on the table, asleep and intubated.
He looked helpless, just like they all do. They are nearly naked when they are wheeled in, sometimes shivering in a room kept at 65 degrees so the surgeons don’t dehydrate with sweat under all their layers. Strange equipment surrounds them, including a big blue table against the wall, covered with the metal instruments that will soon be inside them.
They’re usually not too anxious, thanks to the wonders of modern pharmacology. During a brief anesthesia rotation, I prepared a few patients for the OR, and I tell you, it is a powerful feeling to take syringe in hand, inject a few drops of liquid into an IV line, and watch your patient melt from tension into a casual mood.
In the OR, if they are able, they shimmy themselves from the transport cart onto the operating table, dragging their assorted tubes. They feel their arms go out to their sides in an almost religious motion, taped onto boards so that monitors can be attached. Looking up at the lights they see the mask come over their face. The anesthesiologist injects a syringe of milky fluid into the IV, and within seconds the room is gone.
Mr. G’s incision was at 3:35 p.m. The scalpel skimmed along the stomach skin, raising drops of blood that the attending surgeon zapped with a cautery like a pen in her right hand, raising smoke and a familiar smell. They were moving fast, faster than I’ve ever seen an abdomen opened: down through the fat, through the fascia, through the peritoneum, all within minutes, and into the abdominal cavity.
Blood poured out immediately, and the organs spilled out from the pressure, and the surgeons pawed over them, digging the suction down into the abdomen to reduce the pool of blood, frantically digging down, down toward the spleen, the source of the problem, moving fast, balancing delicacy and force, and they dug the spleen out from the left upper quadrant: ‘Clamp. Clamp. Metz. Clamp. Clamp. Lap. Lap. Clamp.’ The spleen was huge, the size of a child’s head, with a ruptured outer membrane and cracks in it, and it came out with a slosh. It was 3:40 p.m.
Things cooled down. The main source of bleeding was stopped. At a slower and more deliberate pace, they cauterized residual bleeding, sewed up the vessels that had run to the spleen, and inspected the other organs.
I had been trying to help, suctioning here and there, holding back the abdominal wall, holding clamps, trying to stay out of the way. Now, with a second, I looked down at my body, in a Gore-tex gown, with latex gloves, smeared and splattered with blood, drying and turning brown in the bright light.
It all felt ancient, with an urgency and a joy and some sort of primal, predatory feeling related to being immersed in blood. Nothing was held back. All the instincts down to the toes were used by those two surgeons, all the parts of the brain. I know it; I felt it in them.
I’d like to have a PET scan of surgeon’s head during one of these things. PET imagery shows areas of high metabolism in yellow; the whole brain would probably light up like a Christmas tree, right down to the reptilian parts.
Afterwards, I tore off my mask and cap, and walked out into the hallway. I had been sweating. Everything looks different after a surgery. You walk into the hallway and for a few minutes everything you see, everything in the hospital seems to belong to you. There is no deeper level than the one you are on. Everything is for the benefit of your work. No one can stare you down.
It’s seductive. It can draw you in, and own your life. It amplifies arrogant tendencies, eats up hours and days and years, and destroys families.
A friend of mine, laughing at himself, said that during his surgery rotation he began to feel angry in traffic at people who just wouldn’t get out of his way - didn’t they understand how important he was?
I walked into the men’s room to wash up. There was a speck of blood on my forehead.
MEMO: Merrill is a resident physician and former reporter who works in Buffalo, N.Y.
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