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SPOTLIGHT: The First Cut

The surgical rotation can be both surreal and sublime

The New Physician January-February 2007
His suturing was as perfect as it could possibly be. He did his work slowly, not only because there was plenty of time, but because he was so profoundly moved by the task assigned to him.

As a medical student, Dr. Darshak Sanghavi, now a pediatric cardiologist and an assistant professor at the University of Massachusetts Medical School, had been asked to close the incision in the chest of a brain-dead teenager whose heart had just been removed for transplant. The care he took and the reverence he felt for the families involved is characteristic of many students’ initial experiences in
the operating room. Here, third- and fourth-years are confronted with extraordinary and sometimes surreal moments that blend the spiritual, psychological and scientific parts of their lives. It can be a dizzying catharsis that sets them on an unswerving path toward a surgical career.

Chirag Patel, a second-year at the University of Arizona College of Medicine, remembers the day he held a patient’s cold heart in his hand while the attending told him, “Whatever you do, don’t move.” He didn’t move, but the patient’s heart did, picking up a pulse as he held it, warming as it surged back to life. “I was just as happy as I’ve ever been. It was spiritual. I thought, ‘Wow, doctors have so much power,’ if you will, in that they can completely change someone’s life,” Patel says.

Of course, it’s a long route from “don’t move,” to the mastery of a scalpel, but even with the sleepless purgatory of residency around the corner, not one of the surgery-bound students interviewed for this article doubts that he or she is on the right path.

John Braca, a third-year at the New York Medical College who is planning a career in neurosurgery, phrased it this way: “I don’t regret choosing something bigger than myself.”

Theater of the Absurd

To a medical student, an operating room is one part sterile-field sanctuary and one part chrome-bedecked coliseum populated with green-smocked gladiators. And it’s a place where reality can actually change shape. Steel nerves or not, the first time witnessing a surgeon drill through a patient’s skull, or a baby being born, requires a new way of comprehending what’s happening right in front of your eyes.

Take, for example, the hallucinatory experience of watching a maxillary osteotomy. The surgeon begins by disconnecting the patient’s upper jaw so the mid-face slides forward, “like a drawer in a bureau,” says Dr. Jeffrey Lewis, who performs the procedure frequently in his plastic surgery practice in Ithaca, New York. Once the upper jaw is detached, the very shape of this person’s face is in the hands of the surgeon. Almost like a Halloween mask, the skin follows as the surgeon slides the bone forward, and one of the tenets of normalcy—faces aren’t supposed to do that!—dissolves right in front of you.

And then, whoosh—another med student slumps to the floor.

“The first time, I just about lost it,” Lewis says. So in preparation for the second time, he studied up, reading everything he could about the operation “so I could wrap my brain around the concept.” And then it came to him in a stirring flash. The same operation became “so cool. I knew I had to learn how to do that,” he says.

Helping his surgeon father repair an infant’s cleft palate was an unforgettable moment for Jon Black, a fourth-year at the University of Nebraska College of Medicine, who had decided some months before to become the third consecutive generation in his family to take up plastic surgery. During the operation—one of the first he’d ever seen—Black was struck by the enormity of his father’s skill and the swift completion of a procedure that would allow the child to drink without drowning and click her tongue on the roof of her mouth.

“That was probably the surgery that had the most profound effect on me,” Black says. “Because I saw the surgery, I immediately saw the results of the surgery, and then I saw the effect it had on the patient’s family.” And, he says, he saw his father “completely differently” from that day on.

For Braca, a pterional craniotomy was about as good as it gets. Neurosurgery called to him like a trumpet calling to a young Miles Davis. At the moment he watched surgeons remove the front quarter of a patient’s skull, Braca recalls, “I realized that all the things I had been learning and all the things I did in med school all led to this moment.”

That jolt, he said, was accompanied with “amazement that technology and knowledge even allowed such a thing [as neurosurgery] to exist,” and the sense that he had, “in a way, become a part of it…. It was the realization of one of my dreams and the realization that I was ready to go forward,” he says.

Derek Jenkins, a fourth-year at Dartmouth Medical School, says he feels so engrossed and “in the moment” on the surgery ward that an 80-hour workweek doesn’t even register as work at all.

Jenkins was, in fact, studying engineering at Dartmouth when he witnessed the surgery that changed his life. “Here I am, 19 or 20 years old, an engineering student faced with going into the OR,” Jenkins recalls, “and I remember being in awe of Hitchcock [Medical Center], this huge hospital.”

As a member of an engineering lab team that was researching how to improve artificial knees, he had been invited to attend a bilateral knee replacement performed by Dr. Michael B. Mayor, a professor of surgery and an adjunct professor of engineering at Dartmouth, who is now retired.

Jenkins did not scrub. He was told to stand against the wall. It was requested that if he felt faint, he not collapse in the sterile field. But far from passing out, he became enthralled with the procedure. He was most impressed by the way Mayor and his team, which included a second surgeon for the second knee, an anesthesiologist, residents, nurses and students, all worked in orchestrated unison, communicating with eyebrows, small touches and minimal words.

Mystery Dance

“It’s a lot like a dance,” Jenkins says, referring to surgery’s nonverbal communication that takes place with subtle touches, much like leading a waltz partner with one hand held high and one hand on the small of her back.

The patient aside, surgery is “a physically intimate kind of thing,” says New York Medical College fourth-year Jennifer Dore. “Attendings or residents will put out a hand, and someone knows what they want and they give it to them. If things go right, there’s that chemistry, and there’ll be no word spoken at all. It’s really cool, that in itself. It’s one of the reasons I love being in the operating room.”

But for a student exposed to the OR for the first time, the choreographic nuances can be mystifying. You want to participate in the dance, but you don’t know how to act, what to say, where to stand or how to scrub. You don’t know your logical place in the room, but you suspect—and you’re right—that you rank even lower than the observing medical device sales rep, because at least the only mistake he can make is to talk out of turn.

And the student is keenly aware that in the OR, calamity waits in every corner. It happened on University of Nebraska fourth-year Matt Gawart’s third surgical rotation. An aorta that ruptured on the operating table brought on the collective realization that the patient, who had walked unaided into the emergency room less than an hour before, was now, suddenly, dead. And, while no one was blamed, the feeling that there were “a million things we could have done differently” churned in Gawart’s brain, he says, for the better part of a week.

Yet for every guilt-inducing loss, there are emergency surgeries that miraculously foil death. But it is still a tough blow, Gawart says, when a life ends in front of your eyes.

A Delicate Balance

Keeping a healthy perspective on life and death is a balancing act that
challenges every would-be surgeon. “Moving on, so it doesn’t affect the rest of your surgeries that day” is a necessity that comes with the territory, Gawart says. The next surgery could bring a patient back to her feet, pain-free for the first time in months. The one after that could disclose a body rife with too many tumors to count or to curse. Yet, “As soon as you depersonalize, you’re not doing everything you can,” says third-year Milton Little of the University of Michigan Medical School, who is following his grandfather’s footsteps into the noble profession. “Without that emotional attachment [to the patient], I feel like I’d be cheating myself,” he says.

This balance of attachment and detachment can be seen in the darkly humorous stories surgeons commonly share with each other. Remember that time, someone might say, when a junior resident noticed that the Teflon replacement for a clogged artery, en route from the middle abdomen to a leg, had inadvertently tunneled right out of a fold in an obese patient’s belly and back into his body again, unobserved by one and all?

That wasn’t even the funny part, says the established surgeon telling this tale (and who happened to be the former junior resident in question). It was the 15-minute debate on who would have to go tell the temperamental surgeon, who had already left the room, that the patient, who was waking up on a gurney while they argued, had a tube exiting and re-entering two folds of his abdomen.

Who eventually told the surgeon? That would be the lowest-ranking (i.e. the most expendable) person in the room, of course. With visions of his career ending almost before it began, the junior resident fetched the surgeon with the vague confession that “something went wrong.”

At that, the surgeon returned to the OR and leaned over the patient for a full minute. He then uttered something quite memorable:

“I hate it when I do that,” the surgeon said.
Anthony C. Hall is a freelance writer in Dryden, New York.