I proposed a deal to my fellow student on our surgery rotation. “You can have all the other cases today if I get the laryngectomy.”
“Sure,” he sighed apathetically. “Whatever you want.”
A total laryngectomy involves dissecting through the thyroid gland and small muscles of the neck to expose a person’s airway. Intricate blood vessels and elusive nerve fibers are navigated to obtain a clean view, and then the connection from the patient’s mouth to their windpipe, including their vocal cords, is removed. A new hole is created in the front of the patient’s neck that allows air to reach their lungs. Important nerves that affect a person’s ability to smile, move their tongue, shrug their shoulders, turn their head, and take a deep breath are all at risk. At the end of the case, patients’ are left unable to speak. This surgery is usually performed to treat an aggressive cancer, and it is always high-stakes.
Laryngectomies are rare at my training hospital and I did not want to miss the opportunity to participate. My eager feet bolted down the stairs towards the pre-operative area, galloping in asynchronous parallel with my racing mind. I strained to remember textbook images I had reviewed the night before, knowing the anatomy would be much more disorienting in the flesh than in glossy labeled pages.
I restrained my eagerness as I introduced myself to the patient for the first time. It would be callous and insensitive to show such genuine excitement for a procedure that was about to render her permanently mute. She was more weatherworn than I expected; her withered frame was easily overlooked beneath the stack of impersonal hospital blankets specially engineered to shed fewer fibers. Her raspy greeting was barely audible over the maelstrom of surrounding nurses, patients, and alarming monitors. I wondered if she used as few words as possible out of shyness, physical pain, or if she was already trying to prepare for life after her surgery.
When we finally arrived in the operating room, our patient tightly shut her eyes after one glance at the carefully arranged surgical instruments that would take away her organic voice. A heaviness nestled deep in my diaphragm that made each breath feel more drawn out and deliberate. The permanence of what we were about to inflict on this scared woman was oppressive and inescapable. I felt guilty wondering if the surgery I was so eager to be a part of would feel worthwhile to her in the end.
I took extra care in helping to position the patient on the table and explained every step before touching her. “These wraps will massage your legs and help prevent blood clots. I’m going to put them around your calves now.” She silently nodded, and I wrapped them twice around her child-sized limbs.
“These foam pads will protect your heels from developing sores.” Another nod, smaller this time.
“I’m going to place this belt around your waist to protect you from falling.” This time she opened her eyes with a look that wondered if I was crazy, but she nodded a third time.
Per hospital protocol, the full operating room team reviewed our patient’s information and imminent procedure before the anesthesiologist put her to sleep. Sallow, heavy lids shielded her gaze from the harsh lights above, but tears rolling down her cheek betrayed the otherwise stoic demeanor lying supine on the table. The anesthesiologist dammed her silent weeping with sedative medication and two pieces of tape.
Twenty-five minutes later, my guilt ebbed away as I watched the attending and resident dissect down, plane after plane, identifying anatomy in views I had only seen in pictures. I reveled in the novelty of it all. I was having fun. There was no conscious patient for whom I needed to reign in my excitement; I was in the company of surgeons. Jubilant violins and soulful folk singers warbled over the speakers to soundtrack our work. I felt the internal crescendo of each pulsating artery and elusive nerve safely dissected out of harm’s way. I no longer noticed my own breathing or any other feeling in my body; it was as if I was hovering a few inches off the ground, weightless and unrestrained. I felt personally lighter with every lymph node and tissue section removed from the patient’s throat.
After the incisions surrounding our patient’s delicate new airway were coated with bacitracin, everyone in the room broke away for their respective jobs. The attending took his music and left to call the patient’s far-away family. Over the drone of the room’s ventilation, the resident clacked away on a keyboard in the corner to write the operative note. The nurses were at the back table double-checking their instruments to ensure nothing was left behind, while the anesthesiologist read monitors and titrated medications. For a few moments, I was the only person to just stand and be with our patient. I watched her chest rise and fall in the midst of activity that was entirely about, yet did not involve, her at all.
As she began waking from anesthesia, I instinctively reached down and held her forearms to the bed as her hands started to reach up. Patients regaining consciousness can inadvertently injure their eyes and dislodge breathing tubes and IVs, and I didn’t want anything unexpected to happen on my watch. As I pinned her arms to the bed, fear-filled hazel eyes pleaded with mine as I used increasing force to keep her arms down. “Your surgery is all done. It went really well. You’re still waking up in the operating room. Just rest your arms down!” I commanded her, hoping she would stop fighting me.
Tentatively she tried to speak, but had been rendered completely mute by our scalpel. The only sound she could make was a soft pucker from her parting lips. I fumbled through an attempt at lip reading that frustrated us both. She gave up trying to speak and instead of lifting her arms up, she pushed them out to the side. I decided to let go, but she reached out and took my hand between hers. She smiled at me as I finally understood the word I failed to make out moments before: hand. I had been restraining a defenseless, frightened woman from trying to hold my hand.
In my overzealous effort to protect this woman from herself, I lost sight of what was happening in front of me. A vulnerable person who trusted us felt scared and alone, and she needed to be shown that we would be there for her and she would be alright. I moved so blindly through the motions of doing my job that I failed to recognize the most basic need for human connection.
We inflicted massive, irreversible damage to remove a tumor that might kill her anyway. Did we miss the mark there too in our enthusiasm to do good? This woman was counseled extensively about her treatment options, but it is difficult to ignore even the quietest whispers of guilt and self-doubt. There is often no clear answer for when the most aggressive treatment is the best one, and I worry that my excitement for innovative procedures will obscure what future patients need most. I might not get it right every time, but will try to be worthy of their trust, listen to what they tell me, and help them wake up by holding their hands.
Contributing Writer
University of Massachusetts Medical School
Madeline is a member of the Class of 2021 at the University of Massachusetts Medical School. She received her BA in Public Health Studies from Johns Hopkins University in 2014 and MMSc in Immunology from Harvard Medical School in 2017. Her primary literary interest is short narratives, and she enjoys being outside and sending snail mail in her free time.