Let me describe what it’s like to operate in a potentially disastrous situation. Notwithstanding having one’s faculties and wits gathered and finely honed, being as in command of yourself as you can possibly be, it may test and demand everything you can bring to bear. I’ve been in war, where I feared daily for my life. It’s not pleasant, but in some way you can get used to it. In my situation, at least, the odds were with me. Potentially ending or severely altering the life of someone in my charge, on the other hand, having to forge ahead knowing the next move could literally be fatal — that’s uniquely surgical, I think. You’re in the position of making that fatal move, as opposed to responding to one made at you. I’ve been in situations where I’ve failed to save a severely injured person. It feels terrible. But it wasn’t something I caused.
On one occasion during my internship, I was holding retractors while a professor was trying to extirpate a large pelvic tumor. I don’t remember the details — probably the ensuing river of red washed them out of my brain. What I clearly recall, as if I were carrying the picture in my wallet, is the shock at how fast the field filled with blood. That’s the way it is when the iliac vein is breached: it’s big, it’s flimsy, and it doesn’t hold a stitch very well. And it’s connected immediately to the vena cava, the biggest and bluest of them all. Whenever you approach it — as is the case with any major blood vessel — you want to have wide access to it. You need “proximal and distal control,” meaning the parts of the vein north and south of where you plan to work need to be readily available, cleared, and ready for clamping. Dissected out, maybe slung with rubber loops.
With a large tumor blocking the view, it can be impossible. So the surgeon worked his way around the mass while, I’d have to assume, being aware and worried about what lay beyond. Whether he lost his way, didn’t anticipate the anatomical distortion, or just came up snake-eyes, I can’t say. But when he lacerated the vein during dissection, blood poured out like a prison break, and the tumor blocked any possibility of controlling the flow upstream. Blindly placing sutures, frantically replacing blood — whatever was done, it didn’t work.
I’ve been there. Working deeper into the pelvis when the view is distorted by a huge tumor, stuck to the sidewalls, the bladder, puckering normal anatomy beyond recognition. Forced to do something about a nearly undecipherable mass of indeterminate origin, causing obstruction in multiple parts of the bowel stuck to it. Wanting a bailout way of avoiding opening the door to disaster, but finding none.
“OK,” I’ll say. “We could get into big trouble here. Let’s take a minute to get everything ready.” I suggest to the anesthesiologist that he/she start a couple more IVs. Get matched blood in the room; failing that, be sure they’ve got a supply of O-negative blood available (In a pinch, you can give it to anyone). Get the cell saver (a machine for reusing the patient’s spilled blood) in here. Open up some vascular clamps. Wait until it’s all there. And, because when I want to focus all of my attention, I like to open an emergency pack of silence, I tell everyone in the room to stop loose talk and to shut off the music. (I usually like music in the OR, except in deep and challenging situations.)
There are other disaster scenarios, but the iliac vein/pelvis scenario is especially evocative for me, having seen what I saw those many years ago. I’m sure it’s not unique to surgeons or physicians. In some cases, our approach is shaped by the memory of a single impactful event. I’ll say this: it has a way of marshaling all of one’s faculties.
As frightening as it is, in some measure, it’s also thrilling to experience oneself become so focused — to literally blot out everything else in the world — and, like a living lens, to direct all input to a single centimeter of space, to have time become meaningless and imperceptible. Perhaps paradoxically, despite sensing my breathing speeding up, being aware of my rising pulse rate and of drops of sweat sluicing down my sides — even needing to pause for the ultimate cliché, the wiping of one’s brow by a nurse (I’ve dripped sweat into wounds before — and flushed it away with lots of saline) — my hands don’t shake. But yes, as I carefully and clear-headedly dissect my way into the area, as patiently as I know how, at some level, I’m scared as hell. And although while in the midst of it, there’s confidence that I can carry on as long as necessary (like sound and extraneous thoughts, physical discomfort shrinks into insensibility), when the tense part is over, physical exhaustion can well up with surprising suddenness and depth. My neck stiff, my back bent, and my knees hyper-extended, feeling sorry and sore.
I suppose there’s a sense of accomplishment, but it’s more like having dodged a bullet — of having lucked out. Knowing it easily could have gone in another direction, feeling like you never want to do that again, it’s hard to feel pride. Only relief. As much as I believe that the way to handle complications is to avoid them in the first place, and as hard as I work to follow that path, the feeling — even when pretty sure there was no other option — is one of second-guessing whether I missed an alternative to skating on such thin ice. I couldn’t do it every day.
Sid Schwab is a retired surgeon who blogs at Surgeonsblog and is the author of Cutting Remarks: Insights and Recollections of a Surgeon.
