Through a Surgeon's Eyes (eBook)

The year was 1959. It was 5:00 a.m., still cold and dark outside. I was at the nursing station on the chest ward waiting for the new chief surgeon to arrive. I was dressed in my “whites,” the uniform of a junior surgical resident: short white coat, white shoes, white pants, white shirt and tie. We were starting “rounds” early that day, since an open-heart surgery was to be attempted. So far, the record at the hospital was not good. Five open-heart surgeries had been attempted at the Veterans Hospital in West Los Angeles, and five deaths had followed. The fields of heart and vascular surgery were in their infancy. Of course, surgeries were attempted only on the sickest hearts. Without surgery, the deaths of these patients were imminent, making the risks of undertaking open-heart surgery warranted.

The heart-lung machine had been developed to pump and oxygenate the patient’s blood outside his body, allowing a patient’s heart to be stopped. This was quite an advance! Innumerable animals had been sacrificed in laboratories all over the world in order to develop such a device. Drugs were available to paralyze the heart once the patient was “on bypass,” thus allowing the surgeon to operate on the stilled heart. Blood thinners were available to keep the blood from clotting during a procedure. At the conclusion of the operation, an electric shock was applied to the heart to stimulate it to begin to beat again on its own. Most of the people on the surgical team had their own hearts stop in that moment, waiting for the patient’s heart to resume beating.

I trained in surgery from 1957 to 1962. Just prior to that time, the heart was considered “off limits,” an inviolate organ. In doing chest surgery, or any surgery, every move made was with a view to avoid touching the heart. It was feared that the mere touching of the heart could send it into an abnormal rhythm from which it might not recover. Over the following years, many drugs were developed to reduce this hazard and make the subsequent surgeries possible. But until that time, most surgeries that were done in the chest were operations on the lung, primarily for lung cancer. Those surgeries were long and difficult, with cures few and far between. Heart surgery was very new.

My chief was a very young, brilliant, and talented surgeon. Hired to begin the open-heart program at the hospital, he was quite tyrannical, unfriendly, and very demanding of those around him. He was hard-driving and not loved by his staff. Perhaps those were the very traits his job required.

I was a second-year resident in surgery. Above me on the chest surgery rotation was the senior general surgery resident, the resident in chest surgery, and then the new chief. The two residents above me let me know that, no matter what went wrong on the chest service, I would be the one blamed. Both of them, as did I, needed the recommendation of the chief in order to advance in the program. I was the lowest one on the totem pole, and it was obvious that everything bad was going to flow to me, while everything good would be credited to the two residents above me.

The chest ward was a cavernous room, poorly lit, and with faded yellow paint on the walls. Fifteen white iron beds on each side of the room faced each other. They each had a small nightstand alongside the bed. When privacy was needed, a screen was wheeled in to shield the patient from the others on the ward. Of course, everything that was said could be heard by the other patients.

“Rounds” were made twice a day. A heavy steel cart containing a chart for each patient was wheeled onto the ward from the nursing station. I was the “wheeler” as we went from bed to bed, examining each patient, writing orders, discussing the case amongst ourselves, listening to the patient’s questions, and explaining to the patient what needed to be done. I carried a clipboard and wrote down the items that the more senior doctors wanted accomplished on each case that day. It was my responsibility to have those items completed by day’s end.

At one patient’s bedside the chief asked me to order an amyloid test. I had heard of amyloid disease, but had never seen a case. I duly noted the request on my clipboard. Then, after orders were written, we were all off to the operating room to begin the day’s surgical cases. On the day of an open-heart case there was no time to complete any of the other things that had been discussed or written down. Those chores were saved for later in the day.

It was pretty obvious that I would not see daylight on that day, not an uncommon happening. I usually started my workday in the dark and finished in the dark. Of course, now things are different: Each patient’s data is recorded on an iPad, and all things pertinent to the case are entered, as are new orders. No more heavy chart rack. Paperless is now the word.

When our troop arrived in the operating room, the patient was already on the operating table. The anesthesiologist was busy starting IVs, putting in lines to monitor the arterial pressure, central venous pressure, and pulmonary artery pressure, connecting the patient to monitors, and setting up medications to address any anesthetic emergencies that might occur during the operative procedure. Tubes were placed in the patient’s windpipe and in his bladder. The chest was then shaved, the skin prepped, and sterile drapes applied. Four of us then “scrubbed.” We were gowned and gloved by the surgical nurse, and the operation began.

Meanwhile, the pump technician was preparing the heart-lung bypass machine in anticipation of the operation successfully proceeding to the point where the heart could be stopped. Generally the open-heart procedures took five or six hours to complete. Most of the time was spent with a great deal of tension in the room. Just opening and closing the chest took a good deal of time. Our chief was the operating surgeon. The chest resident stood across the operating table from him. The surgical resident stood alongside the chief, and I was relegated to standing to the right of the chest resident. From my vantage point I could see nothing of the surgery. But I was required to be there just the same. Most of the time my job consisted of holding retractors which had been positioned by the surgeon to afford him a clear view of the surgical field. I wasn’t supposed to move, no matter how long the surgery took. It was physically very taxing.

To convey an idea of the physical demands of a five-hour operation, imagine placing a book in which you are very interested on the kitchen counter, almost the height of an operating table, and reading for five hours without moving from the spot—no breaks for the bathroom, a drink of water, or even moving around just to get the kinks out. In addition, most of the time you are not working looking straight ahead. That was my situation. In some ways, the surgeon is even worse off. Twisting and bending are part of the surgeon’s job and, as a result, most surgeons end up with chronic back or joint pains in their later years.

In the midst of the surgery the chief looked at me and asked, “What did the amyloid test show?” I was stunned. I meekly answered that I had been by his side since 5:00 a.m. and hadn’t had time to order the test. He looked at me and snapped, “That’s no excuse.” He then resumed operating.

The case did not go well from the start. The patient was quite unstable throughout the surgery, multiple transfusions were required, and various drugs were needed to maintain his blood pressure. The tension mounted throughout the room. After five hours the operation ended, and the patient was weaned off the heart-lung machine. An electric current was applied to the heart, which began beating again, and normal circulation was restored. But the heart rhythm was abnormal, so a pacemaker was implanted in the heart muscle to maintain a regular rhythm. The patient was then moved to the recovery room. All of the monitors were connected, the respirator adjusted, blood gases were checked, blood sent to the laboratory for various tests, urine output noted, and things started to settle down.

The chief did not want to lose this patient. He was frenetic, going around and around the bed adjusting this and that, checking the respirator and blood oxygenation. With the pacemaker operating, the EKG monitor showed the pacemaker impulse, but not the patient’s own heartbeat pattern. As I was working on him, I suddenly remembered that if he died, no matter what the cause, I was going to get the blame. I slowly backed away from the bed. The chief was so focused on the various monitors that he didn’t even notice that I wasn’t helping. After about an hour, he finally turned to me and asked, “Have I forgotten anything?” I looked at him and, in a steady voice, I said, “Only one thing.” He was somewhat startled and exclaimed, “What?” I replied, “I think your patient is dead.” He stared at me for a few seconds while my remark registered and then he turned and shut off the pacemaker. There was no electrical activity on the heart monitor. The patient was—and had been for some time—dead.

Without a word, the surgeon turned on his heel and left the room. It was up to me to turn off all the monitors, take out all the pipes and tubes, and call the morgue. It was also up to me to talk to the family and tell them...