“Knife.” One of the surgical nurses slapped it into his hand, and Dr. James drew the scalpel quickly down the woman’s betadine-covered belly. So little fanfare preceded that moment that I almost missed it. The incision was a good eight inches long, and there wasn’t any blood. “Bovie.” There was a faint buzzing sound, and then the doctor began to trace the Bovie down the incision like it was a scalpel. The surgery began as Dr. James and his partner Dr. Lake cut through the deeper layers of skin and fat over the woman’s abdomen.
I was standing in an operating room in my local hospital as part of the student shadowing program. That morning, in the gray light of a predawn cafe, Dr. Lake had told me about the day’s case, the repair of an enterocutaneous fistula in a woman who developed complications following a hysterectomy. I had researched a bit about the surgery, a symptom of my pathological need to impress everyone with how much I know about everything, and learned the surgeons would be correcting an abnormal connection between the bowel and the surface of the skin.
The patient strapped to the operating table with a growing incision in her belly hardly looked like the same woman I’d met earlier in pre-op. After I’d changed into my scrubs, marveling at how the softness of the many-times-washed fabric and the unfamiliar smell of hospital detergent sent a thrill through my stomach, Dr. Lake brought me on his final pre-op check. He quickly reviewed the risks and steps of the procedure one last time. She barely spared me (introduced as a “student helping out today”) a second glance, giving me a little smile that didn’t reach her eyes. I remember being surprised by her age, early forties at most. The patient turned back to Dr. Lake and nodded some more as the doctor spoke. He turned to leave with a cheerful, “You ready?” She replied quickly, “Oh yes. Let’s do this.”
The harsh lights, the smell of burning fat, and incongruous top 40 radio pulled me back to the OR where the surgeons had reached a layer of abdominal muscles covering the belly cavity. They continued to carefully dissect down using the Bovie when suddenly a spurt of bright red blood shot into the air, splattering across the sterile drapes and up the front of Dr. Lake’s surgical gown. The team immediately flew into a flurry of action which lasted all of about two seconds and ended with Dr. James’s reassurance. “I’ve got it, I’ve got it. Get me a silk tie.” One of the nurses hurried off, and Dr. James remarked, “Must have been a little artery.”
Dr. Lake turned to me, wide-eyed behind my facemask. “Did it get on my face?” he asked. I nodded yes with a little giggle at the sight of the blood splashed over his mask like some kind of TV drama. “Did it get up here?” he said, gesturing towards the head of the table where I was standing. I shook my head. “Good. But –ˮ he called out to the nurses, “get the girl some eye protection!” Someone handed me a pair of plastic safety glasses, and the operation continued.
Although now surgery is used to treat a huge variety of conditions caused by disease, birth defects, accidents and old age, in its early years it focused on treating the casualties of violence. The advancement of medicine is dependent on wide scale suffering, on the sacrifice of millions on the altar of progress. If necessity is the mother of invention, then war is the mother of medicine. Innumerable life-saving leaps in medical technology and surgical technique have their roots on the blood-soaked battlefields of the Sorbonne, the beaches of Normandy, the snows of Stalingrad. The discipline of surgery is steeped, literally and figuratively, in blood. There is no other field of knowledge or expertise that owes so much to human suffering. On the front lines of the battle between life and death, the most formidable tool to improve health is often the knife, connecting harm and healing in an odd and anomalous union.
Dr. Lake and Dr. James opened the peritoneum. The innumerable loops of pale, shiny small bowel were visible from where I stood craning my head to see over the drapes bounding the sterile surgical field. There was the strangest feeling of familiarity when I saw the intestine — I’d never seen inside the body cavity of a living person before, and yet everything seemed instantly recognizable. So often the body is presented as the most complex machine ever created, and rightfully so. Hundreds of disparate biochemical processes must work together with numerous diverse physical stimuli and stresses to keep the body functioning well. But seeing the belly laid open like that with everything where it should be was like walking into a room with everything in place on the shelves. Some part of me recognized what I was seeing; it seemed like the most natural, common thing.
The anesthesiologist next to me at the head of the table asked if I was doing all right. I nodded vigorously, keeping my eyes glued to the movements of the surgeons’ rubber-gloved and blood-covered hands. I was more than all right. I’d never in my life been so thrilled to see something, to be somewhere. Given the choice between a ticket to a Hollywood red carpet premiere and four more hours in that cold, impersonal room, I don’t think I would have moved. Something had drawn me to the bloody, high-stakes world of surgery, some unusual allure that couldn’t be explained. It left me with a connection to that room, to that field, to that feeling of discovery and astonishment and power — a connection I never would have expected to form.
When I’d entered the operating room before the surgery, trailing timidly but eagerly behind Dr. Lake, the nurses were already hard at work arranging the patient and placing safety straps around her. They were talking and laughing. I stood in a corner afraid to touch anything, afraid to get in the way, awed by the irreverence of these people whose job day in and day out was to save lives. These people were taking on some of the responsibility of life and death, yet here they were, gossiping about their children and yesterday’s cases and arguing over what kind of music Dr. James would want played during the surgery. It seemed so disconnected from the fact that this was a place where people bled, were cured and sometimes died. Nonetheless, the atmosphere of the room and the truth of what happened inside of it were linked in some convoluted and inexplicable way.
The surgeons quipped back and forth over the open body on the table, talking about their kids and Dr. Lake’s country club. Dr. James and his wife had just had a new baby. Dr. Lake told a mock-exasperated story about taking his four girls out to dinner at the country club and trying to get them to finish their dinners. The nurses ganged up on Dr. James to tease him about his Minnesota Vikings scrub cap, a complete no-no in the heart of Green Bay Packer country. I was surprised at how the staff and the doctors interacted so casually and amicably, showing each other pictures on their phones, making jokes, commiserating over the lack of snacks in the lounges. The fact that a large part of their daily routines directly impact, sometimes crucially, the health of hundreds of patients in a hospital does not deprive them of lightness and banter. Their work, some of the most delicate, difficult and crucial work on the planet, is overlaid and woven through with laughter and jokes and excitement, a mess of intertwined capillaries and tissues that cannot be easily picked apart.
As they began the closure, Dr. James and Dr. Lake agreed that in order for the incision to heal flat, they should remove the extra triangle-shaped flaps of flesh that had been created when they extended their incision. They did so, hacking and burning with the Bovie, removing a good nine centimeters of skin and fat and tissue on either side of their original incision. The sections were lifted clear and handed off to a nurse, destined for medical waste. As the final piece of connective tissue was severed, Dr. Lake gave a little giggle, like a kid pulling a prank. “They always freak out when they wake up with no belly button,” he said.
At the time I was so caught up in the adrenaline of surgery that I just giggled along with him. But now I pause. This woman had already lost her ability to have children, and now these surgeons had taken her only physical connection to her own mother. Since her earlier hysterectomy, there was no longer any bodily maternity left to her. Although she was alive and she would be healthy, which was the most important thing to everyone involved in her case, this act speaks to the necessary arrogance of surgeons and even in a strange way to their ignorance. Surgeons are proud residents of the land of the concrete. It is one of the things that drew me to the field, actually; surgeons have the ability to take a severely ill patient, to identify her problem and to fix it in a matter of hours. There is little uncertainty about what is causing the patient’s discomfort when the belly is gaping open, revealing inflamed intestines or inguinal hernias. There is no speculation about inaccessible mental processes, no waiting and hoping for drugs to take effect. Their firmly tangible lives and jobs can sometimes blind surgeons to the intangible. The same surgeon who has seen more of a patient’s body, inside and out, than any other human being can still be ignorant of what is going on with that patient, mentally or emotionally.
For surgeons, having blood on their hands — and their clothes, their arms, and occasionally their faces — is an ordinary part of the day. They do not have the luxury of indulging the body’s natural response to the sight of the massive injuries they have purposely caused. They must shut down the part of their mind that screams out in horror when they slice a patient open. They must forget that they are cutting living, thinking, feeling human flesh. In order to do the necessary work, surgeons must dehumanize the patient temporarily; they must separate their conception of the patient as a person from the tissue in front of them. Yet reducing the patient to a problem to be solved or a broken machine to be repaired strips her of dignity and humanity. The surgeons I was watching did not stop to consider the consequences of an action that they thought was harmless and medically necessary. They did not stop to imagine that maybe they were encroaching on this woman’s bodily autonomy, that they were casually removing a part of her that could have great meaning tied to an idea of motherhood and womanhood they did not understand. They simply saw flesh that needed to be removed, cut it out, threw it away and then made a joke. The surgeons might not realize the gravity of what they had done, but the patient will know. The caring healers became unwitting violators, connecting two actions, two results, that could not be further apart.
Before they had closed the patient’s incision, Dr. James and Dr. Lake had begun to prepare the intra-abdominal mesh. The nurse held up boxes of mesh one by one, calling the dimensions out to Dr. James who considered them, staring at the patient’s half-closed abdomen, before asking for a ruler. I was confused. Why did he need a ruler? He wasn’t going to measure the space inside this woman’s belly with a ruler, was he?
He was. The surgical tech handed him a small flexible ruler and he dove right in, placing the ruler into the abdominal cavity. I watched as it became splotched with the blood clinging to the doctor’s gloves. “Fifteen by twenty,” he said, and the nurse consulted her boxes. She handed him one containing a sheet of mesh larger than needed. “Can I get a marker?” asked Dr. James.
I looked on with awe as Dr. James pulled the mesh from its box. It looked for all the world like a thick, textured piece of paper – almost like a preschooler’s construction paper. Dr. James took his little ruler, stained from its adventure inside a human body cavity, and started to measure – fifteen centimeters one way, twenty the other, connect the marks with straight lines along the edges of the bloody ruler. “Scissors,” Dr. James called. He began to cut the mesh, carefully following his marker lines. The rest of the operating room went about their business as I watched a board-certified surgeon, a medical professional with close to fifteen years of training, cutting his piece of now-dirty mesh into a rectangle like a preschooler making a clumsy cut-out house. It was craft time in the OR.
Dr. James held the mesh against the exposed abdominal muscle, squinted a little, and then pulled it back out. He picked up his scissors again and rounded off the mesh’s corners freehand. I was glad the facemask I wore hid my stunned expression. Dr. James held up his mesh masterpiece, gave a satisfied nod, and placed it over the patient’s sutured-together abdominal muscles. He and Dr. Lake tacked the mesh in place, pulled the next layer of muscle over top, and began to suture.
This is the image that comes to me now when I say I want to be a surgeon. I see an unbelievably qualified and intelligent man with a pair of bloody scissors. I see the care with which he measured; I see those Crayola-crisp black lines he drew. There was something so heartbreakingly, hopefully human about it. No machine or fancy robot was saving this woman’s life, just a man and his hands. There is a connection there, maybe the most intimate connection possible. These patients are at their most vulnerable as they lay naked and unconscious on an operating table. They trust the surgeons to put their hands inside their bodies, to touch their organs and reroute their blood vessels and rebuild their lives. There is Dr. James, carefully trimming his mesh, doing a job any of his nurses could have done with respect and kindness and care. There is the connection again, the shimmering, fragile, unexpected tie that links these two contrasting things: the bloody wound, the aggressive surgeon with his shining blades and needles; and the subtle, intimate image of his hands carefully guiding the scissors around the edges of his hand-drawn guidelines, healing this woman one cautious snip at a time.
There is a little joke that patients like to make as they walk out of their last appointments for some kind of acute surgical problem. The surgeon bids them goodbye, and they turn with a little smile on their faces. They respond, “Goodbye. I hope I don’t see you again soon!” The surgeons chuckle and agree. They wave the patient off, but I can’t help but wonder if it hurts a little that the nature of their jobs is such that everyone is happy to leave them. The surgeon performs the most important service anyone can. He saves a life. The patient thanks him, of course, and then says, “But I never want to see you again.” Surgeons agree; an absent patient is a healthy patient, and giving the patient the ability to walk away is the goal of all surgical teams. Still, I wonder if it hurts when the patient walks away, when that strange, invisible, profound connection is severed. The linkage between restoration and suffering is unusual, irregular, and maybe even unintentional, but it is important. Surgeons know that it is part of their jobs to cut this link between them and the patient. It is, after all, a joining that was never meant to be, that in a perfect world would not exist. But that bond does exist, and then it is undone. It is repaired, restored to normal. That is good; but I still wonder if it hurts.
*Names have been changed to maintain patient privacy and confidentiality.