Complications (3 page)

A resident, however, begins with none of this air of mastery—only a still overpowering instinct against doing anything like pressing a knife against flesh or jabbing a needle into someone’s chest. On my first day as a surgical resident, I was assigned to the emergency room. Among my first patients was a skinny, dark-haired woman in her late twenties who hobbled in, teeth gritted, with a two-and-a-half-foot-long wooden chair-leg somehow nailed into the bottom of her foot. She explained that the leg had collapsed out from under a kitchen chair she had tried to sit upon and, leaping up to keep from falling, she inadvertently stomped her bare foot onto the three-inch screw sticking out of it. I tried very hard to look like someone who had not just got his medical diploma the week before. Instead, I
was determined to be nonchalant, world-weary, the kind of guy who had seen this sort of thing a hundred times before. I inspected her foot and could see that the screw was imbedded in the bone at the base of her big toe. There was no bleeding, and, so far as I could feel, no fracture.

“Wow, that must hurt,” I blurted out idiotically.

The obvious thing to do was give her a tetanus shot and pull out the screw. I ordered the tetanus shot, but I began to have doubts about pulling out the screw. Suppose she bled? Or suppose I fractured her foot? Or something worse? I excused myself and tracked down Dr. W, the senior surgeon on duty. I found him tending to a car-crash victim. The patient was a mess. People were shouting. Blood was all over the floor. It was not a good time to ask questions.

I ordered an X ray. I figured it would buy time and let me check my amateur impression that she didn’t have a fracture. Sure enough, getting one took about an hour and it showed no fracture—just a common screw imbedded, the radiologist said, “in the head of the first metatarsal.” I showed the patient the X ray. “You see, the screw’s imbedded in the head of the first metatarsal,” I said. And the plan? she wanted to know. Ah, yes, the plan.

I went to find Dr. W. He was still tied up with the crash victim, but I was able to interrupt to show him the X ray. He chuckled at the sight of it and asked me what I wanted to do. “Pull the screw out?” I ventured. “Yes,” he said, by which he meant “Duh.” He made sure I’d given a tetanus shot and then shooed me away.

Back in the room, I told her that I would pull the screw out, prepared for her to say something like “You?” Instead she said, “OK, Doctor,” and it was time for me to get down to business. At first I had her sitting on the exam table, dangling her leg off the side. But that didn’t look as if it would work. Eventually, I had her lie with her foot jutting off the end of the table, the board poking out into the air. With every move, her pain increased. I injected a local anesthetic where the screw went in and that helped a little. Now I grabbed her foot in one hand, the board in the other, and then for a moment I
froze. Could I really do this? Should I really do this? Who was I to presume?

Finally, I just made myself do it. I gave her a one-two-three and pulled, too gingerly at first and then, forcing myself, hard. She groaned. The screw wasn’t budging. I twisted, and abruptly it came free. There was no bleeding. I washed the wound out, as my textbooks said to for puncture wounds. She found she could walk, though the foot was sore. I warned her of the risks of infection and the signs to look for. Her gratitude was immense and flattering, like the lion’s for the mouse—and that night I went home elated.

In surgery, as in anything else, skill and confidence are learned through experience—haltingly and humiliatingly. Like the tennis player and the oboist and the guy who fixes hard drives, we need practice to get good at what we do. There is one difference in medicine, though: it is people we practice upon.

My second try at placing a central line went no better than the first. The patient was in intensive care, mortally ill, on a ventilator, and needed the line so that powerful cardiac drugs could be delivered directly to her heart. She was also heavily sedated, and for this I was grateful. She’d be oblivious to my fumbling.

My preparation was better this time. I got the towel roll in place and the syringes of heparin on the tray. I checked her lab results, which were fine. I also made a point of draping more widely, so that if I flopped my guidewire around by mistake again, I could be sure it wouldn’t hit anything unsterile.

For all that, the procedure was a bust. I stabbed the needle in too shallow and then too deep. Frustration overcame tentativeness and I tried one angle after another. Nothing worked. Then, for one brief moment, I got a flash of blood in the syringe, indicating I was in the vein. I anchored the needle with one hand and went to pull the syringe off with the other. But the syringe was jammed on too tightly, so that when I pulled it free I dislodged the needle from the vein.
The patient began bleeding into her chest wall. I applied pressure the best I could for a solid five minutes, but her chest still turned black and blue around the site. The hematoma made it impossible to put a line through there anymore. I wanted to give up. But she needed a line and the resident supervising me—a second-year this time—was determined that I succeed. After an X ray showed that I had not injured her lung, he had me try again on the other side with a whole new kit. I still missed, however, and before I turned the patient into a pincushion he took over. It took him several minutes and two or three sticks to find the vein himself and that made me feel better. Maybe she was an unusually tough case.

When I failed with a third patient a few days later, however, the doubts really set in. Again, it was stick, stick, stick, and nothing. I stepped aside. The resident watching me got it on the very next try.

Surgeons, as a group, adhere to a curious egalitarianism. They believe in practice, not talent. People often assume that you have to have great hands to become a surgeon, but it’s not true. When I interviewed to get into surgery programs, no one made me sew or take a dexterity test or checked if my hands were steady. You do not even need all ten fingers to be accepted. To be sure, talent helps. Professors say every two or three years they’ll see someone truly gifted come through a program—someone who picks up complex manual skills unusually quickly, sees the operative field as a whole, notices trouble before it happens. Nonetheless, attending surgeons say that what’s most important to them is finding people who are conscientious, industrious, and boneheaded enough to stick at practicing this one difficult thing day and night for years on end. As one professor of surgery put it to me, given a choice between a Ph.D. who had painstakingly cloned a gene and a talented sculptor, he’d pick the Ph.D. every time. Sure, he said, he’d bet on the sculptor being more physically talented; but he’d bet on the Ph.D. being less “flaky.” And in the end that matters more. Skill, surgeons believe, can be
taught; tenacity cannot. It’s an odd approach to recruitment, but it continues all the way up the ranks, even in top surgery departments. They take minions with no experience in surgery, spend years training them, and then take most of their faculty from these same homegrown ranks.

And it works. There have now been many studies of elite performers—international violinists, chess grand masters, professional ice-skaters, mathematicians, and so forth—and the biggest difference researchers find between them and lesser performers is the cumulative amount of deliberate practice they’ve had. Indeed, the most important talent may be the talent for practice itself. K. Anders Ericsson, a cognitive psychologist and expert on performance, notes that the most important way in which innate factors play a role may be in one’s
willingness
to engage in sustained training. He’s found, for example, that top performers dislike practicing just as much as others do. (That’s why, for example, athletes and musicians usually quit practicing when they retire.) But more than others, they have the will to keep at it anyway.

I wasn’t sure I did. What good was it, I wondered, to keep doing central lines when I wasn’t coming close to getting them in? If I had a clear idea of what I was doing wrong, then maybe I’d have something to focus on. But I didn’t. Everyone, of course, had suggestions. Go in with the bevel of the needle up. No, go in with the bevel down. Put a bend in the middle of the needle. No, curve the needle. For a while, I tried to avoid doing another line. Soon enough, however, a new case arose.

The circumstances were miserable. It was late in the day and I’d been up all the night before. The patient was morbidly obese, weighing more than three hundred pounds. He couldn’t tolerate lying flat because the weight of his chest and abdomen made it hard for him to breathe. Yet he absolutely needed a central line. He had a badly infected wound and needed intravenous antibiotics, and no one could find veins in his arms for a peripheral IV. I had little hope
of succeeding. But a resident does what he is told, and I was told to try the line.

I went to his room. He looked scared and said he didn’t think he’d last more than a minute on his back. But he said he understood the situation and was willing to make his best effort. He and I decided that he’d be left sitting propped up in bed until the last possible minute. We’d see how far we got after that.

I went through my preparations: checking the labs, putting out the kit, placing the towel roll, and so on. I swabbed and draped his chest while he was still sitting up. S., the chief resident, was watching me this time, and when everything was ready I had her tip him back, an oxygen mask on his face. His flesh rolled up his chest like a wave. I couldn’t find his clavicle with my fingertips to line up the right point of entry. And already he was looking short of breath, his face red. I gave S. a “Do you want to take over?” look. Keep going, she signaled. I made a rough guess as to where the right spot was, numbed it with lidocaine, then pushed the big needle in. For a second, I thought it wouldn’t be long enough to reach through, but then I felt the tip slip underneath his clavicle. I pushed a little deeper and drew back on the syringe. Unbelievably, it filled with blood.
I was in
. I concentrated on anchoring the needle firmly in place, not moving it a millimeter as I pulled the syringe off and threaded the guidewire in. The wire fed in smoothly. He was struggling hard for air now. We sat him up and let him catch his breath. And then with one more lie-down, I got the entry dilated and slid the central line in. “Nice job,” was all S. said, and then she left.

I still have no idea what I did differently that day. But from then on, my lines went in. Practice is funny that way. For days and days, you make out only the fragments of what to do. And then one day you’ve got the thing whole. Conscious learning becomes unconscious knowledge, and you cannot say precisely how.

I have now put in more than a hundred central lines. I am by no means infallible. Certainly, I have had my fair share of what we
prefer to call “adverse events.” I punctured a patient’s lung, for example—the right lung of a surgeon from another hospital, no less—and, given the odds, I’m sure such things will happen again. I still have the occasional case that should go easily, but doesn’t, no matter what I do. (We have a term for this. “How’d it go?” a colleague asks. “It was a total flog,” I reply. I don’t have to say anything more.)

But then there are the other times, when everything goes perfectly. You don’t think. You don’t concentrate. Every move unfolds effortlessly. You take the needle. You stick the chest. You feel the needle travel—a distinct glide through the fat, a slight catch in the dense muscle, then the subtle pop through the vein wall—and you’re in. At such moments, it is more than easy; it is beautiful.

Surgical training is the recapitulation of this process—the floundering followed by fragments, followed by knowledge and occasionally a moment of elegance—over and over again, for ever harder tasks with ever greater risks. At first, you work on the basics: how to glove and gown, how to drape patients, how to hold the knife, how to tie a square knot in a length of silk suture (not to mention how to dictate, work the computers, order drugs). But then the tasks become more daunting: how to cut through skin, handle the electrocautery, open the breast, tie off a bleeding vessel, excise the tumor, close up the wound—a breast lumpectomy. By the end of six months, I had done lines, appendectomies, skin grafts, hernia repairs, and mastectomies. At the end of a year, I was doing limb amputations, lymph node biopsies, and hemorrhoidectomies. At the end of two years, I was doing tracheotomies, a few small-bowel operations, and laparoscopic gallbladder operations.

I am in my seventh year of training. Only now has a simple slice through skin begun to seem like nothing, the mere start of a case. When I’m inside, the struggle remains. These days, I’m trying to learn how to fix abdominal aortic aneurysms, remove pancreatic cancers, open blocked carotid arteries. I am, I have found, neither gifted nor maladroit. With practice and more practice, I get the hang of it.

We find it hard, in medicine, to talk about this with patients. The moral burden of practicing on people is always with us, but for the most part unspoken. Before each operation, I go over to the preoperative holding area in my scrubs and introduce myself to the patient. I do it the same way every time. “Hello, I’m Dr. Gawande. I’m one of the surgical residents, and I’ll be assisting your surgeon.” That is pretty much all I say on the subject. I extend my hand and give a smile. I ask the patient if everything is going OK so far. We chat. I answer questions. Very occasionally, patients are taken aback. “No resident is doing my surgery,” they say. I try to reassure. “Not to worry. I just assist,” I say. “The attending surgeon is always in charge.”

None of this is exactly a lie. The attending
is
in charge, and a resident knows better than to forget that. Consider the operation I did recently to remove a seventy-five-year-old woman’s colon cancer. The attending stood across from me from the start. And it was he, not I, who decided where to cut, how to isolate the cancer, how much colon to take.

Yet to say I just assisted remains a kind of subterfuge. I wasn’t merely an extra pair of hands, after all. Otherwise, why did I hold the knife? Why did I stand on the operator’s side of the table? Why was it raised to my six-feet-plus height? I was there to help, yes, but I was there to practice, too. This was clear when it came time to reconnect the colon. There are two ways of putting the ends together—by hand-sewing them or stapling them. Stapling is swifter and easier, but the attending suggested I hand-sew the ends—not because it was better for the patient but because I had done it few times before. When it’s performed correctly, the results are similar, but he needed to watch me like a hawk. My stitching was slow and imprecise. At one point, he caught me leaving the stitches too far apart and made me go back and put extras in between so the connection would not leak. At another point, he found I wasn’t taking deep enough bites of tissue with the needle to insure a strong closure. “Turn your wrist more,” he told me. “Like this?” I asked. “Uh, sort of,” he said. I was learning.