Monday, September 7, 2015
Our lives are full of firsts.
Parents wait for their baby’s first tooth, first words and first steps.
We may remember our first day of school, first solo bicycle ride without training wheels, first automobile drive, first date, first kiss, first sexual encounter and others that I don’t recall at the moment.
A surgeon also has firsts.
I clearly recall the first surgery I ever saw. Now, you might think that because I am the son of a surgeon that my childhood was replete with trips to the hospital with my father where I accompanied him into the OR and became his right hand man at the age of thirteen.
On rare occasions I did go to the hospital with my father when he made rounds, but the closest I ever got to an operating room was sitting on a bench outside the gift shop, watched over by the volunteer behind the cash register while my father went upstairs to see his patients.
There were occasional conversations at the dinner table which delved into the world of surgery:
Dad: “Dr. A, the anesthesiologist, is getting a divorce. Isn’t his wife, Betty, in your Bridge Club?”
Mom: “She’s the reason the bottle of Scotch is almost empty.”
Dad: “Well, she was sleeping with Dr. K while Dr. A went off and spent a weekend with one of the nurses in the OR.”
Mom: “I guess I’ll need to somebody new for the Bridge Club, one who doesn’t like Scotch. Anything new at work?”
Dad: “My new office nurse is pregnant.”
Mom: “You mean the one who said she hadn’t been able to get pregnant for two years? She’s only been with you for two months.”
Dad: “I guess some of the Gelber fertility rubbed off on her,”
Mom: “That’s the third nurse who’s gotten pregnant in the last eighteen months. And, none of them had been able to get pregnant before.”
Dad: “It must be something in the air.”
There have been many important “firsts” over the years. I remember my first day of medical school when I was introduced to Herman, my anatomy group’s cadaver, a constant companion through the first semester and Sigrid, last name Gelber, my lab partner, adopted sister and friend through medical school and afterwards until her death from breast cancer at the far too young age of 35.
Then there was my first day of Internship, a Sunday, when I arrived at the hospital where I was greeted by a list of patients and instructions from my second year resident to make rounds, do the necessary H&P’s on the new admissions and he would see me the next day. This particular resident, not surprisingly, was fired before the year was out and is now tormenting surgeons as an anesthesiologist.
It was in medical school that I actually witnessed my first operation. I was assigned an advisor, Dr. C. Nelson, a Neurosurgeon. His job was to smooth the transition from the rigors of college to the even greater exactitudes of medical school. I don’t remember much of what he did, except that he invited me to watch an operation. He was performing a transsphenoidal resection of a Pituitary tumor the following day. Finally, something more than the formaldehyde of anatomy and squinting into a microscope in Histology.
I managed to find my way to the OR assisted by an OR nurse who directed me to the locker room where I donned the blue surgical scrubs of Strong Memorial Hospital, 60% Cotton, 39% Polyester and 1% stainless steel.
I managed to find my way to the OR room where the operation was about to commence. I managed to come within six inches of contaminating the scrub tech’s back table, while I looked upon the patient, prepped and draped with her upper lip pulled back, exposing her teeth and gums.
“This patient has Nelson’s Syndrome caused by a tumor in her pituitary gland,” Dr. Nelson explained. “We’ll approach the pituitary through her sphenoid sinus, which is behind her maxilla.”
I nodded my head, then asked, “Is Nelson’s Syndrome named after you?”
“I wish,” he answered, “that was a different Dr. Nelson.”
I watched as the Chief Resident began the surgery, incising above the teeth, removing bone and finally reaching the pituitary gland. An operating microscope was wheeled into position and Dr. Nelson began the real operation. I was able to watch through a second teaching port.
I saw some reddish tan stuff and then some yellow gray gunk and then I saw Dr. Nelson tease the yellow gray gunk away from the reddish tan stuff.
“The thin grayish tissue is the adenoma. She’s making too much ACTH which is causing her adrenal glands to secrete too much cortisol, resulting in her having Cushing’s disease.”
“I thought you said she has Nelson’s Syndrome?” I asked in my ignorance.
“Nelson’s Syndrome is causing her to have Cushing’s disease,” he explained, displaying far more patience than I deserved.
After a few hours the operation was finished. The Chief Resident closed her up, sealing the surgical site with some fat and superglue.
“It looks painful,” I commented as he glued the bone back in place, while I considered what it would feel like to have someone cut me along my upper gums.
“Surprisingly not,” the Chief Resident responded.
“How do you learn to do such an operation,” I wondered out loud.
“I take notes, read about the technique, assist on cases and then do the surgery,” he answered. “It’s all about studying and observing.”
One thing he didn’t mention was innate talent. When I finally began doing surgery I realized that natural ability and technical skill was something that could be taught only to a certain extent. Truly great surgical technicians are born, not made.
It was years after this first experience with surgery that I actually performed my first real surgery. It was my first month of internship and I was on call when Peter was admitted to the “Resident’s” service. He’d had pain for three days, with nausea, vomiting and elevated White Blood Cell count. He had exquisite tenderness in the Right Lower Quadrant of his abdomen. Peter was a textbook case of acute appendicitis.
It was about seven pm when my Chief Resident, Dr. S and his Attending, Dr. T. joined me in the OR for Peter’s appendectomy. I had read the book on appendicitis and studied the technique over and over.
The surgical tech handed me the scalpel and I began to make my incision.
“Your shaking like a Goddam Parkinsonian,” commented Dr. T.
I did shake a little, but not enough to interfere with the actual surgery.
Once the incision was made, I switched to the electrocautery and buzzed the bleeders in the skin edge and then made the incision deeper until I saw the diagonal fibers of the external oblique fascia. Just like in the book I incised in the direction of the fibers and retracted this muscle.
“Take a Kelly clamp and split the muscle of the next layer along the direction of their fibers. First with the muscle, then perpendicular to it, so that it spreads apart. By the way, which muscle is this?” Dr. S asked
“Internal Oblique,” I answered without losing a beat.
“Right. If you didn’t know, then I would have to take over the surgery,” He added.
The Internal Oblique and Transversalis muscle fibers were split apart exposing the peritoneum.
“Clamp,” I requested.
The scrub tech slapped it into my hands, just like in the movies.
I picked up the peritoneum with the clamp.
“Another clamp for my assistant,” I said, a bit too softly.
“Another clamp for my assistant,” I replied, much more loudly.
“OK, OK, you don’t have to yell,” the tech added.
I opened the peritoneum and some cloudy fluid poured out.
“Culture,” I said loudly and I was handed a swab.
“Now, put your finger in and see if you can feel the appendix,” Dr. S instructed.
“I feel something hard,” I replied.
“Let me check,” he suggested as he put his fingers through the opening in the peritoneum. “That should be the worm (nickname for the vermiform appendix, the complete name for the appendix); see if you can flip it up into the wound.”
I put my finger in and swept it around the offending organ and it came into view. It was swollen to the size of a Hebrew National Knockwurst.
“Don’t grab the appendix,” Dr. T. barked. “Find the cecum.”
Years later another Attending surgeon, Dr. Bronsther taught me this one surgical nugget about appendectomies, the only thing I ever learned from him.
“Appendectomies are surgery of the cecum.”
What he meant was that the appendix always arises from the cecum, which is the first part of the colon. It is always found where the three Tenia coli, which are the three longitudinal muscle layers which are seen on the colon, coalesce. Over the many years I’ve been doing appendectomies, these two pearls of wisdom have served me well.
Back to Peter. I identified the Cecum and gabbed it with a Babcock clamp and delivered it up into the wound. Once enough of it was protruding through the wound, I grabbed it with a sponge, rocked in back and forth until the entire cecum popped into the wound, followed by the very swollen and inflamed appendix.
Now it was time to actually do the surgery, that is remove the sick organ.
“Wait, wait,” Dr. S. said forcefully.
The three of us stared at the swollen appendix, greatly enlarged all the way to its base. The normal procedure would be to divide the mesoappendix, which carries the appendiceal artery, ligating the blood vessels, then divide and ligate the appendix close to the Cecum, usually leaving a small stump. There was controversy in those days about inverting the stump or merely tying it. The consensus was that simple double ligation was appropriate. Inverting the stump potentially created future problems.
“Start with the mesoappendix?” I wondered out loud.
“Right,” Dr. S. agreed.
We clamped along the fat which led to Peter’s appendix and then tied each blood vessel within the clamp until the appendix was free from any attachments all the way to the Cecum. There was a short segment, about three millimeters, of normal appendix.
“Clamp it there?” I suggested, pointing to the uninflamed stump.
“Yeah, but use a Kelly on the appendix side,” He added.
Clamp, clamp, cut and that sick appendix was gone.
“O Vicryl tie?” I requested, a touch of doubt in my voice.
“Right,” my assistant agreed and we’ll need some 2-0 Vicryl stick ties, also.
We tied off the appendiceal stump and then sutured the cecum over this ligature. I admired my handiwork for a moment.
“Put it back where it belongs, Dr. Halsted,” Dr. S. ordered, “the patient’s not getting any younger.
I closed him up, irrigating and suturing each layer before stapling the skin closed. Peter was wheeled off to Recovery as I trailed slightly behind holding his chart and sporting a big grin on my face. He went on to an uneventful recovery.
Years later, during an interview, I was asked about my most memorable moments. I cited two:
My wedding day and Peter’s operation.