In an operation, sometimes, there are moments when I can’t turn back and I really can’t go forward. I have to wait and see. Doing more can be worse. Today, I used a surgical stapler to divide the blood supply to a part of the gut of a patient, something I have done, literally, a thousand times. This time, the tissue that held the blood supply swelled and the gut turned a little grey. Maybe a vein was laying in an odd orientation, maybe I was off five degrees. Surgeons like pink and lively tissue. Grey is bad, and black is dead. Less than pink means the blood supply is compromised. As I watched, the portion of intestine I was working with peristalsed (pushed, like a snake in Mr Knapp’s first grade class or Mr Steele’s third grade class would push a mouse through) and fought against the compromised blood supply. It was as if the bowel was striving against the stress. It was interesting. How can I be detached enough to simply observe this bad situation and still care about what is happening? Not sure, but I know I can. Partly it is because it is not happening to me. I know that sucks, but it’s the truth. It’s how you get through the tragedies in your friends‘ lives too maybe.
Surgery is not like a cartoon event. The blood vessels of interest are hidden in laminates of tissue and I make decisions based on where the vessels usually are. Plus I am doing Nintendo surgery, operating through small incisions while looking at an HD screen. All those endless hours (loved each one), blowing my tips from my busboy job at Pelican’s Wharf, playing Asteroids, paid off in my operating now on video screens and using sticks without wrists to dissect, cut and sew. All that to say this: I can’t exactly see the vessels I cut sometimes. I bet you would like your surgeon to swim in clear blue seas at all times, but it’s not like that, sometimes. Sometimes it is murky.
The bowel got dusky, swelled. It was not a portion I could remove or bypass..or ignore. I really had no outs. I could make up an operation in which that portion was taken out and I pulled up a limb and sewed it in there but it would seriously jeopardize the rest of the operation, put her at huge risk, etc. “Technically feasible” does not always mean “wise to do”. (True in many parts of life).
So I did nothing, waited. I moved along with some other parts of the operation and checked back in with my partially devascularized limb of small intestine. It looked a little better as time went on. I think collateral vessels were coming to the rescue. Fortunately our bodies are made with redundancy after redundancy to make up for our behavior, injuries (even injuries like surgery), overwhelming waves of of the inevitable, our twenties, etc.
An hour later things were still marginal and my outs had not changed. I did nothing, which for a surgeon, is doing something. Surgical wisdom is often defined by the cases or maneuvers we don’t do, by the things we pass on, by the practice of restraint and trust in the patient and her body to work with what was my best in the moment. A surgeon who does any and every case that comes her way is one to avoid. “No” is often a good indicator of someone thinking.
All this happened today. I am home now. My patient is in her room, vital signs all ok, skin all closed up. I can’t see what it going on with her tender loop of small intestine. I am worried, but I am in the gap and waiting. It’s all I can do, and all I should do.
There are lessons here, and I know you see them. Me too, I guess, but mostly I am pondering my skill and her anatomy and the foibles of humans working with each other, on the contact sport of surgery. She is floating and I am floating with her, between places and I will not leave her until we get somewhere.