Doing Harm (5 page)

I make a vertical incision in the center of Mr. Bernard’s abdomen from just below his belly button to just above his penis, where the DO NOT REMOVE is still faintly visible through the sterile, brown iodine solution that now covers his skin as if someone had spilled a bottle of thick maple syrup all over him.

I slice through the skin and enter the bright yellow fat lying immediately underneath. The scalpel is sure and sharp. As I cut through the fat, which is packed full of small blood vessels, the bleeding starts, and my white gloves are immediately dappled with irregular splotches of bright red blood, which transform my hands into something resembling two moving Jackson Pollack canvases, working in sync to open Mr. Bernard’s belly and expose its contents to the outside world. I cut down quickly through the layers of fat to his abdominal muscles.

“Knife down.” I turn and lay the scalpel down carefully on the instrument tray behind me.

“Thank you,” the scrub nurse replies, whisking the scalpel away.

There is a fundamental ethical principle that governs the practice of medicine. It sums up in one succinct phrase the basic rule all physicians are expected to follow when treating their patients, the one that the colonial-era founders of University Hospital felt compelled to incorporate into the hospital’s official seal more than two hundred years ago.

Primum, non nocere.

I first heard it spoken during my first year of med school from one of my older professors who had a proclivity for bow ties and Grecian Formula. He spoke the words with great flourish, reverently lingering over each syllable, caressing the Latin pronunciation as lovingly as he would his children. He attributed the phrase to the Greek physician Hippocrates, the doctor whose ancient oath freshly minted doctors recite each year at medical-school graduations around the world.

Now, I’m no historian, but I remembered thinking at the time that Hippocrates was a Greek who had lived hundreds of years before the Roman Empire, and wondered if Latin really would have been his idiom of choice for solemn ethical declarations. In fact, I’ve since learned that it was actually Galen, a medieval doctor and translator of Hippocrates’ writings, who was probably the one who coined the Latin variation.

But, whatever. Doctors like to say stuff in Latin because it makes us sound smart. And, anyway, the essence of Hippocrates’ message is the same in any language.

Primum, non nocere
.

First, do no harm.

Well, when a surgeon operates, he or she
is
doing harm. Sometimes massively so.

Surgery is a violent art. It’s the act of healing through deliberate injury to the human body. Scalpels slice through healthy skin to allow access to the diseased organs hidden underneath. Otherwise robust muscles are unceremoniously pushed and pulled and shoved out of the way and held out of the surgeon’s working space—the “operative field”—for hours at a time with blunt metallic instruments called retractors.

Normal blood vessels are burned and strangled with fine sterile threads called sutures and cut with scissors, innocent bystanders felled by the surgeon’s relentless march through the healthy parts of the body that invariably stand between the outside world and the site of the patient’s disease.

In a way, then, the very act of surgery itself is a violation of one of the most fundamental ethical principles in the practice of medicine. The most iconographic and essential tool of the surgeon—the scalpel—is in essence … what? Nothing more than a really sharp knife, a variation on one of the earliest tools a human being ever conceived of to hurt other human beings.

The surgeon wields the scalpel with the intent to heal. The violence wrought is controlled, calculated, and precise. But it’s still violence, nevertheless—pure and simple and primeval.

Another tool we surgeons use to cause harm is the electrocautery. Nicknamed the “Bovie” after its inventor, James Bovie, the electrocautery is like an electric scalpel. To cauterize means to destroy living tissue with heat, cold, or chemicals. The Bovie uses the heat produced by an electric current to burn through tissue. It’s a pen-shaped instrument, held in the dominant hand just as you would hold a pen, with a metal tip on the end that directs an electric current into the patient at the point where the tip touches the patient’s body. The surgeon switches the current on by pushing a button on the pen. As the current passes from the pen and into the patient, it meets resistance, which generates heat, which burns the things the metal tip is touching: skin, fat, muscle, whatever.

As the tissue at the point of contact between the Bovie’s metal tip and the patient vaporizes, it produces a wisp of bluish-tinged smoke that carries with it a singular odor.

The odor of burning human flesh.

I pick up the Bovie and cauterize the bleeding vessels. The heat from the Bovie cooks the fat, and I inhale the familiar smell.

God, I love operating.

I can’t believe they pay me to do this.

I’d do it for nothing.

I can’t imagine what I’d do with my life if I couldn’t operate.

When most of the bleeding has stopped, I put the Bovie down, then spread Mr. Bernard’s abdominal muscles apart with my fingers. They pull away easily from each other, and I immediately know that I’m in the right place—between the left and right bellies of the rectus abdominus muscles, at the midline of the abdominal wall, which is the easiest, surest way into the interior of the abdomen from here. Next, I take a pair of scissors from the nurse and cut through the rest of the gossamer-like tissue lying between Mr. Bernard’s bladder and me. Now my hands are inside Mr. Bernard’s abdomen, probing and sweeping and searching. His insides are warm and moist, closing around my hands as if I had put them into a vat of warm Jell-O.

I’m fast. Andrews must have gone to get coffee or something because by the time he comes back, I’ve set up the metallic retractors, and, with the nurse’s help, I’ve taken out all the lymph nodes from Mr. Bernard’s pelvis. I’ve cut through blood vessels and fat to properly expose the bladder and prostate gland for the next part of the operation: the important and more dangerous part, when Andrews and I together carve Mr. Bernard’s bladder and prostate out of his body.

This is what it’s all about. This is why I went to med school in the first place. Operating is a total rush for me. I can’t get enough of it. The feeling is indescribable; it’s pure exhilaration.

A friend of mine in college used to like to say that pizza is a lot like sex: When it’s good, it’s great; and when it’s bad, well … it’s still pretty good. I feel the same way about operating. When things go well during an operation it’s absolutely exhilarating; a simple, pure joy that defies description; a jolt of adrenaline that makes you feel like you’re on top of the world.

And when things don’t go so well during an operation, I think it’s still pretty good.

I was never an athlete. Not a serious one, anyway. But some of the surgeons I work with who were big-time athletes in high school and college tell me that when they’re operating well, it’s the closest thing they’ve experienced outside elite competitive sports to reaching that elusive mental sphere known as “the Zone.”

The Zone, these guys tell me, is a mental Nirvana in which time slows down, difficult motions and complex movements are effortlessly and flawlessly executed, and scoring twenty points in the big playoff game—or performing cardiac bypass surgery—seems as ridiculously easy as sitting on the couch with a bag of chips watching TV.

The problem is, you can’t always be in the Zone. No matter what you do for a living, every so often you’re going to have a bad day. A day when you just can’t seem to catch a break, when it’s one bad thing after another, and you’re just trying to make it through to quitting time so you can crawl home, toss back a couple of stiff drinks, and hope to God that tomorrow’s better.

Doctors are no different. Surgeons are no different. Every surgeon has off days, days he or she would prefer to forget, when nothing seems quite right. Some surgeons have more bad days than others, obviously. The good surgeons are generally the ones who can perform well even on their bad days. A bad day for a good surgeon usually isn’t all that bad for the patient. The good surgeons take the bad days in stride, and the patient never sees the difference.

As for the bad surgeons … well, I can only imagine. Whenever things aren’t going too well for him in the operating room, one of my professors (a fantastic surgeon) likes to sigh dramatically and remind me that somewhere in the world at that moment a really, really awful surgeon is having a really, really awful day.

And God help that awful surgeon’s patients on that awful day.

Today, though, there’s nothing bad. I feel great. I guess I’m in that Zone, operating well even for me. One of my professors has told me that I’m the most naturally gifted surgeon to have come through our training program in the last ten years. I just can sense things about the operation; where I’m supposed to go, what I’m supposed to do, the next move I’m supposed to make.

I mean, you can teach a monkey how to operate. But you can’t teach a monkey to do the kinds of things that I can do. I guess I’m just naturally able to take things to the next level. Mr. Bernard would no doubt be surprised, and not a little bit uneasy, to know how much of his operation is being done by me, a trainee. But Andrews, younger and less confident with this operation than some of the older professors, lets me do parts of the operation that I know he would never let any of the other residents do. I practically take Mr. Bernard’s bladder out all by myself, then build him a new one made out of small intestine.

The whole thing takes us about five hours. Toward the end, I notice GG slip into the room to watch the final parts of the procedure. Andrews doesn’t like to be interrupted while he’s operating. Once, a few years ago, I watched him tear into a third-year medical student for asking an innocent but ill-timed question during a particularly stressful part of a stressful operation. Andrews completely lost it, screaming obscenities at her until she finally ran crying from the room.

That kind of behavior, routine back when surgeons ruled as god-kings over their ORs, feared by all and questioned by none, is no longer tolerated by medical schools and hospitals. And with good reason: As soon as her tears had dried, the student filed a formal complaint, threatening a high-profile lawsuit against both the medical school and the hospital—as well as full disclosure to the local press—because Andrews had employed some particularly choice sexual turns of phrase during his hissy fit. I heard that the hospital coughed up a bunch of cash to keep the student quiet and that Andrews had to take some anger-management classes to keep his job.

Classes or not, Andrews’s anger has never seemed particularly well managed to me. So I ignore GG, and she has the good sense to slip into a corner and keep quiet.

We finish the operation, the speed and ease of which have left Andrews in a good mood. “Nice job, Steve.” He extends his hand, and we shake over the juicy red and yellow maw in the middle of Mr. Bernard’s abdomen. “Great hands, as always.”

“Thanks, Bill.”

“You okay to close?” He’s already taking off his sterile gown and gloves, anticipating—or, more likely, not even caring—what my answer’s going to be.

“Yeah, no problem.”

“Thanks. Call me if you need anything.” Then he’s out the door, whistling to himself, without having even noticed GG still standing in the corner.

I now need an extra pair of hands to help me sew Mr. Bernard’s abdomen together.

“GG, you mind scrubbing in and helping me close?”

“Are you kidding? I’m already there.” She rushes out the door and is back in the room as quickly as the scrub protocol will allow.

After putting on her gown and gloves, she slides up to the side of the table opposite me. “Steve,” she asks eagerly, “can I throw a few stitches through fascia? They let me do it on my trauma-surgery rotation.”

I hesitate. Normally, since it’s the strongest layer of tissue that will be holding Mr. Bernard’s abdomen together and his guts inside his body after this operation, I wouldn’t let a med student sew the fascia closed. But I get a good vibe from GG. And, more important, I’m confident I can fix things if she starts to screw up.

“Okay. Give it a try. Are you right-handed?”

“Yes.”

I hand her a needle driver and a set of forceps. The needle driver, which is shaped like a pair of pliers, grips in its serrated jaws a semicircular needle with a diameter the size of a silver dollar. The needle is attached to a bright blue suture as thick as a piece of uncooked spaghetti. The suture, analogous to the thread of a sewing needle, will be what holds Mr. Bernard’s belly together until it heals. The suture will eventually dissolve, but only long after the healing process is complete.

“Okay. Start here.” I point to a spot at the bottom of the incision. GG begins right where I’m pointing, confidently sweeping the needle through the thick white fascia, which has the consistency and strength of beef jerky.

She’s good. She really is. She handles the needle driver and suture with a dexterity and speed I’ve rarely seen in a med student before.

“Nice technique. I don’t normally let med students do this, so I hope you’re enjoying the experience.”

“Oh, yeah. Definitely. Thanks, Dr. Mitchell.”

“No problem. And, again, call me Steve.”

“Thanks, Steve. This is the best.”

I watch her work her way down the length of the incision for a while. “Take wider bites, GG. Catch more fascia laterally. I don’t want to have to reclose this guy in the middle of the night after he coughs, rips his stitches, and his guts spill out. It makes me look bad.” She stops for a moment, unsure, needle poised in midair, her brow furrowed.

“Here. Like this.” I take the back of her hand in my own and gently guide it through the correct motions a few times before letting go.

“Okay, Steve. Sorry.” She adjusts her technique accordingly with an ease that even some junior residents with a good three years of training on them can’t muster.