Watching my first below-the-knee amputation on my surgery rotation, I felt a curious mix of revulsion and detachment. The woman on the operating table had a gangrenous infection that had spread across her foot. Her long history of smoking and her delay in seeking medical care meant that she had stiff, black toes by the time a surgeon first saw her. The only treatment was amputation.
In the operating room, the patient was draped such that only the leg was visible and exposed. The first incision was easy, a semicircle around the calf, and then the surgeons dissected down further until they hit bone. A bone saw sliced its way through the tibia, while the slimmer fibula was taken apart in chunks with a bone cutter. The skin and muscle were cut in a flap; the flaps were brought around over the bone and sewn together to create the stump.
The amputated leg sat on the scrub nurse’s table, next to a tray of retractors. The foot was balanced upright. The skin was smooth until the edge, where it gave way to jagged edges of flesh, remnants of blood vessels, and two cross-sections of bone. I felt unsettled with the amputated portion of the leg so close to me, a graphic reminder of what was lost.
What was it that troubled me? Maybe it had been the ordinariness of the moment when the body was divided up, its fibers severed with precision and focus, but no surprise, no significance. This patient would wake up some hours later, still groggy from the haze of anesthesia. Though she had signed a consent form, though this surgery had saved her, I wondered how she would she feel when she looked down at her leg.
Even in the absence of phantom pains or other sensory reminders of the missing part, dealing with an amputation is hard. It breaks the taken-for-grantedness of the body. It forces people to move through the world in new ways. These experiences made me think, can we imagine any ritual to mark a loss of bodily integrity? A pause to appreciate the work the body has done, and to prepare ourselves for its new form?
I witnessed many bodily transformations on my surgery rotation, as we do in medicine every day. But in our increasingly technical engagement with patients, do we forget the many social and cultural meanings of the body and its parts? Like why a patient may ask for his rib back after it is excised from his chest well to relieve obstruction, or why grieving parents of a stillborn child may want to bury the baby with her placenta? Perhaps a ritual could help physicians recover the awe and the empathy toward bodies we care for, and further connect to how our patients make sense of these changes.
During my transplant surgery rotation, I realized what such a ritual could look like.
I participated in an organ procurement, where we rushed to a nearby city to harvest healthy organs from a young man who had passed away suddenly. We changed from Stanford scrubs into the ones of the local hospital and entered the operating room. Before we began dissecting the abdominal cavity, a nurse read us a paragraph about the person in front of us, telling us of his decision to donate, his hobbies, and the family who survived him.
Then, just as the intricate work of clearing the organs and preparing the blood vessels was complete, the nurse played a song that the family had chosen in memory of their son. I won’t name it here, but it was a tropical song, light and breezy and hilariously out of place given our setting of green and sterile white. The song allowed me a minute to pause at the operating table, to marvel at how this man’s organs — one beating heart, two porous lungs, a pink liver — were shifting and substitutable, and to mark his loss of bodily wholeness.
His song, and his generosity, will stay with me.
Amrapali Maitra is a medical student who blogs at Scope, where this article originally appeared.
