Located in the heart of the city, the emergency room of Detroit Receiving Hospital has its share of colorful patients, from those with gunshot wounds to homeless alcoholics looking for a warm bed and meal. In medical school, I rotated through this emergency room. On my first night, the resident I was following had to start an IV on an IV drug abuser with a head laceration. The resident took the patient’s scarred arm, placed a tourniquet around it and searched for a vein. His arm revealed the rough life he led, with scars and tattoos and leathery skin. The IV needle pierced the skin and then the resident began trying to thread the IV catheter through the tortuous vein, wriggling this way and that, trying different directions. All the while, I’m thinking “that must be painful,” then…..black. The next thing I know, I’m on the hard floor, the bright lights above blocked by a circle of heads belonging to a circle people staring down at me. Yes, I passed out watching someone get an IV. How the heck would I ever become a doctor and overcome the fear of invading someone’s body?
The short answer is that I did. Not only did I survive, I even became a surgeon and actually cut patients open. I vividly remember my first c-section, my first hysterectomy, my first laparoscopy and the nervous excitement of each new experience. How clever that we drape the patient before surgery, with only a small square visible to easily dissociate that there was a whole person there. Obviously, the drape is used to keep the surgical area sterile, but the secondary benefit of this dissociation was not lost to me. Early in my training, I remember looking at the beautifully smooth skin, knowing that the moment I cut into it, it would be scarred forever. With some trepidation, I’d take the scalpel, slice the skin and the tissue underneath, until I reached the diseased ovary or uterus. The attending would be instructing me, assisting, and taking over if I showed any sort of hesitancy. Our hands would bump, dart around each other, or cross in an awkward Twister move.
Even the simplest things, like how to hold a surgical instrument or tie a secure knot required practice and experience. In time, I gradually mastered more complex techniques, intricate dissection of structures like the ureter. Since I worked with so many different attendings, each with different techniques, it was hard to find my own rhythm. There was always something that wasn’t quite right; I should have moved a little this way or that with the clamp, the suture, the cautery. But by the time I graduated, I had honed the techniques in the style I liked, with the sutures I liked, and the moves I liked. Now that I had my dance steps perfected, it was time to lead my own dance.
And so I took the big leap from being a resident on June 30th to becoming an attending on July 1st. As an attending, I was now the one giving instructions, critiquing the residents, and actually doing less of the surgery as the residents needed the experience. Standing in this position allowed me to continue to learn while instructing, although there were still bumpy, jerky moments as the residents weren’t used to my dance moves yet. But what I truly enjoyed was the freedom of scrubbing with one of my partners, our surgical skills complimenting each other, gliding through surgeries effortlessly.
Over the years of practicing together, one of my partners and I did a lot of our surgeries together. We knew each other during residency, he being in the class before mine, and so we had “grown up” together. An outpatient surgery center across the street from our office lacked residents and required us to assist each other. Because we had done so many surgeries together, we created a good rhythm and flow.
My partner had a patient with severe pelvic pain and despite many attempts at trying to treat the pain medically, nothing gave her relief. She was done having children, done with her uterus, and done dealing with the pain. They thus agreed the best plan would be a hysterectomy. Since her uterus wasn’t that big, he scheduled her for a laparoscopic hysterectomy.
On a hot summer afternoon, my partner and I met at the surgery center, changed into scrubs and entered the operating room with the patient. She was soon lulled to sleep, as the anesthesia coursed through her veins. After we put our gowns on, we readied the stage with the drapes, lighting and camera. The dance started slowly, circling the stage, assessing the best approach, the two of us coming from different sides, each offering our perspective. My partner started, bravely piercing the skin with the trocar, the sharp instrument needed to enter the abdomen. We slipped in the camera and saw the sinister, misshapen uterus, causing pain to its host, and needed to be removed. The innocent fallopian tubes and ovaries were tethered on either side, beautifully flowing, unknowing of the disease between them. We then inserted 3 more trocars, taking turns leading by conducting the placement and pace. With all the instruments in place, the waltz could begin with one leading and the other helping to visualize. Lifting the uterus, pulling aside the tube and ovary…. 1,2, 3……clamp, cautery, cut…..1,2,3…..clamp, cautery, cut……. Without words, we glide through the pelvis, our hands moving in rhythm, each anticipating the next step. First I take the lead, bringing down the attachments the uterus has to “my side” of the pelvis, then we switch, always in control of the uterus and protecting the innocent bystanders for they will be staying. As we approach the bottom of the uterus, our movements intensify, we now need to protect the bladder and be wary of the large blood vessels nearby. We pause briefly, then the final swipe and the uterus falls.
We take a moment to catch our breath. In unison, we work to remove the now unattached uterus from the body, me bringing the uterus up to my partner as he cuts it up and brings out the pieces through the small incisions. Once the uterus is removed, we sweep through the pelvis a last time to make sure there is no bleeding and all the remaining organs are safely in place. All the instruments are then removed and incisions closed as the room is full of chatter, the afterglow of a performance gone smoothly and well done. My partner and I remove our gowns and wipe the sweat from our brows. The lights are turned off, the stage is cleared, and the room is emptied. Just before my partner and I part ways, an almost imperceivable bow is exchanged. He talks with the waiting family and I leave through the back door quietly.
Every surgery carries some anticipation and tension. Since every patient is unique, there is no cookie cutter technique to a procedure. Each surgery has to be modified according to the uniqueness of the patient or the disease process. That is the art of surgery and when it goes smoothly or with surgeons that work well together, it feels like a dance. It is a visceral, enjoyable, and, in the end, satisfying experience knowing you have improved someone’s life. As I look back, the work I do now is a far cry from that young medical student who, at first, couldn’t even fathom starting an IV.