A Surgery I Will Never Forget

“Tears wet my eyes. I’m a surgeon. I like solving things. But how do I solve
― Atul GawandeBeing Mortal: Medicine and What Matters in the End

I stood in front of the sink in my stained but washed scrubs, stained with what I don’t know. I turned the two nozzles to 45 and 30 degree angles to get the perfect temperature of water. I reached on my tippy toes to try pushing the soap dispenser handle down with my elbow but I couldn’t quite get it. Dr. A laughed at me, reached over and pushed it with his elbow five times, releasing five squirts of gooey pink soap onto my palm. We went over the scrubbing procedure together: rub your hands together, rub one hand over the other, put your hands in opposite directions and scrub behind your fingers, make circles with your nails onto your palms, etc, etc, etc. Dr. A then told me you have to wash your hands at an angle, always have your fingers pointed upward so the clean water never runs back down your arm. The corner of my mask was poking into my right eye at this point, I felt a burning and watering and I’m pretty sure a tear escaped. We repeated this scrubbing process three times, I was near blind during all three, and then we walked into the room with our hands held up at shoulder height. I pursed my lips and pulled them down under my mask, trying and failing to pull the sharp blue irritant down and out of my eye. We took the white napkins and dried our hands and arms one at a time. We opened the gloves, we touched the right glove with only our right hands, and we touched the inside only. I grabbed the outside of the left glove with my right hand and stuck my left hand in. Pulled the gloves over my sleeves. Dr. A was long finished at this point, kind of just amusingly staring at me struggle to unstick my thumb from the wrong part of the glove. “Can I touch my mask, I need to fix it,” I finally pleaded. “No, you can’t touch it, someone will fix it for you.” The sister came over and pulled my mask down, pinched the nose area so it would stay in its place. Then we proceeded to tie our gowns and we walked to the patient asleep on the table.

A woman, 35 years old maybe. Had to get her kidney removed. She was septic for a week or so, hadn’t moved from the bed. That’s all I really know about her. She had already been anesthetized. Dr. A asked the sister to get a stool for me because I was more than a foot shorter than the doctor next to me without one. The patient was laying on her left side, right shoulder up and right hip pointing toward the ceiling. They had tied some bands around her to keep her in that position, and they put a sticky clear plastic wrap around her body. Dr. A, Dr. B, and I were around the table along with one of the sisters who kept giving the tools to the doctors. “Blade.” Sister handed it over. And we began.

Dr. B incised and blood started oozing out, as I always imagined. By the way, this was my first time seeing a surgery this close. I was literally right next to the patient, my hands were resting on her body. So anyway, yeah blood started oozing out. And this is where I always got confused because how do the doctors keep cutting if there’s blood coming out, wouldn’t that just cause more and more blood to come out? But they use cautery, which I should have known because I’ve seen it before. So anyways, they cauterized the length of the incision and the wonderful aroma of burnt skin filled the air in the operating room. They cut through layers of yellow fat, they cut through protective tissues and blood squirted out at some points. Dr. B turned to me, “just watch your eyes, I don’t want an American lawsuit filed against me.” (I should mention here that this experience obviously did not take place in the US). Dr. A and I laughed, then they went back and forth about how Americans are aggressive with their legal procedures. You know, more than 12% of my experience shadowing at XX Hospital has been doctors rapping on me for being American. Making fun of American politics, shows, actors, musicians, laws . . . these people keep up with American pop-culture better than I do. Anyways, after a few squirts and more cuts and more cautery, we reached the kidney! Or so we thought.

The doctors at this point literally stuck their entire hands into her body. They didn’t make any cuts but they were just rummaging around there doing God knows what. Actually I know what because I asked what. After 10 minutes of them moving their hands around and mumbling inaudibly to each other, I was like “what are you guys doing?” And then Dr. P was like, “mobilizing the kidney.” And I was like, “oh okay.” So that settled that.

The kidney was stuck in there very tightly. They couldn’t mobilize it easily. They had to keep moving their hands around and apparently it was a large kidney. After 30 minutes, they finally mobilized the anterior portion of the kidney. They took it out of the incision and a portion of it was resting on her hip. “Pretty hefty kidney, eh?” Dr. B remarked. This is where things started to get rough. The anesthesiologist started asking questions. “Are you guys pushing on the vena cava?” “Her heart rate has slowed and she has low blood pressure.” “She’s not getting any carbon dioxide output.” “I’m giving her a shot of adrenaline.” And finally, “What is that,” pointing at the organ on top of her body. The doctors were busy at this point doing something else, having another one of those mumbly inaudible conversations. The anesthesiologist asks again, a bit more aggressively, “What is that?” This is where it all clicks, Dr. B realizes they didn’t just mobilize the kidney, they accidentally mobilized the liver. He says, “this is the liver. The kidney is there, we should have gone in from here.” So that moment. That moment he realized his mistake. Everything that was done wrong up to this point and everything that should have been done for it to be right.

So the doctors stuff her liver back into her body, for lack of a better verb. They throw in some gauze as well to stop the bleeding. Dr. B is kind of freaking out this point, although he’s doing his best not to show it. The anesthesiologist is standing up, staring at the screen and announcing the patient is having arrhythmias and still doesn’t have any carbon dioxide. Dr. B asks the sisters to phone Prof C. The doctors are rummaging around her body some more, I wish I knew what they were doing but I’m not sure really. I think they were trying to reposition the liver and check if any important connections were severed. After some more of that, they found nothing was leaking and no immediate damages were found. A moment of relief. The anesthesiologist is still standing and staring at the screen, injecting some things into her body. While the doctors are still doing whatever they’re doing, the anesthesiologist says, “lets stop for a moment. If she doesn’t get better in a minute we’ll have to start CPR.” “Are you serious?” Dr. B shouts but he really wasn’t shouting, he said it in the most calm and collected voice, but really I could tell he was shouting. “Yes, that’s what I’ve been saying,” retorted the anesthesiologist. Then a few moments of silence but never stillness, the doctors were still hands deep inside of her, trying to see what was wrong and if they could fix it. The anesthesiologist gave the call and we start flipping the patient onto her back to start CPR. Her incision is on the right side of her body and as we flip her onto her back, blood oozes through the sheets we placed over the cut. Dr. B starts CPR and the anesthesiologist announces the time we started. He’s reading out information he’s gathering from the screen, “she has output now but she’s still not getting any CO2 which is what is concerning me. It’s not a volume issue. She’s just not getting any CO2. She’s not getting any oxygen now either.” The doctor is still doing CPR, he’s panting at this point because it’s tiring. There is blood dripping all down Dr. A’s hands and onto his gown, forming a puddle of dark red on the ground. The anesthesiologist tells the sisters to turn on the defibrillator and bring it to the patient just in case. They rotate out doctors doing the CPR. 4 doctors do CPR in total. As they push on her heart, her whole body contorts and then decontorts. And then contorts. Prof C asks to see her incision. Dr. A lifts his blood stained hands and we see the organs shift up and down with each push on the heart. We do CPR for 20 minutes. Nothing changes. The anesthesiologist says we must call it. He announces the time of death, 11:35 AM.

And then everyone leaves the room. It’s just the doctors, the anesthesiologist, Prof C, and I. Prof C starts talking about making arrangements for the body, talking to the family. Dr. B and Dr. A start to sew up the incision. Dr. B tries to do it but I can see his hands are shaking too badly to hold the string. Dr. A takes over, he puts large sutures over the incision, but still clean, organized. I feel kind of paused, stuck in space, just watching while everyone is running around still trying to do things. They’re moving forward. A sister walks back into the room and turns to me, “This is your first time scrubbing?” I nod. So there’s just this dead body on the table, the body of a woman who thought she was getting her kidney taken out and thought she would wake up in a few hours with pain in her right abdomen. Instead, she never woke up. It was a pulmonary embolism, the anesthesiologist said. “Just one of those things.”

I didn’t know what to do. I had to go, I had class at noon. I didn’t want to walk up to the doctor sewing up her dead body and say “I have to go, thank you and bye.” Too few words for too great of an experience. I didn’t want to walk up to the doctor and ask one of the million questions running through my head. Not the place or time. So I decided to just turn and walk out of the room without saying anything. I took off the gloves splattered with the blood of a dead woman, I took off the gown that experienced the death, and I walked out. I changed and I went to class and went to yoga and went about my day. The emotional hole you’re supposed to feel when you experience death wasn’t there because I wasn’t emotionally attached to her. I don’t even know her name. But she’s still haunting me in a weird way. Not her, but the situation. Who’s fault was it? What caused it? Could it be prevented in the future? Could we have done anything more during those 20 minutes of CPR to try and save her? Does she have a family? Does she have children? Who tells the family? Who has the job of explaining to the children? Where does the body go? Did a part of her expect this to happen, and did she prepare herself for it? Did she prepare her family for it? How do the doctors and nurses go about their day normally after this? Does it haunt them the same way it’s haunting me? Is surgery a field I want to go into? Is surgery a field I can go into? The operating room, a place that saves countless numbers of lives. Cancer, broken bones, cataracts, car accidents, paralysis, brain injuries, crushed lungs, internal bleeding. Thousands of life-threatening injuries that surgery can save you from. But when surgery goes wrong, when the opposite of what is supposed to happen ends up happening, it’s a surgery that will stick with you forever. She would have been better off not getting the surgery if she had known she would never wake up from it. But she didn’t know that. A bet on her life, but it was a bet lost.

“Surgery was the most difficult thing I could imagine.

And so I became a surgeon.”
― Abraham VergheseCutting for Stone

The Layers of Medicine: My Summer at Stanford

“Can I get a 5:0 Monocryl and 6:0 Fast Absorbing Gut?” I thought after hearing Dr. Aasi repeat the remark over fifteen times a day through the span of my internship I would get tired of the phrase, but the request was precedent to surgery and watching Dr. Aasi perform surgery was number one on my list of preferred summer pastimes. During the short amount of time I was able to spend at Stanford Medicine shadowing Mohs practitioner and surgical oncologist Dr. Sumaira Aasi, I learned more about the nature of doctors and their teams than I did about the details of medicine. Of course I was intrigued by the effectiveness of Moh’s medicine in removing basal cell carcinomas and the many reasons skin grafts can die after being sutured to an open wound and the exact temperature of liquid nitrogen–all fascinating topics of conversation–but the paramount take away from my summer at Stanford was being able to observe the intricate workings of a hospital clinic.

Dr. Aasi and her team resemble a house of cards. It seems as if they can read each other’s minds, always knowing the whereabouts of every patient’s wandering family members and the next tool Dr. Aasi needs placed in her hand. The team flows, with every factor of the equation solved for. One nurse enters a room as soon as the first exits, the rooms are prepped just in time for the doctor to enter, and the slides are presented at perfect moments between surgeries. There is an unspoken understanding of the way things need to go. My first few days of the observership I was following Dr. Aasi around like a lost puppy, equally befuddled and awed at the clockwork that was their clinic.

The Outside: What Field of Medicine?

Dr. Aasi performs surgeries regarding lesions on the skin that can take the form of basal or superficial squamous cell carcinomas, cysts, lipomas, or keloids. Basal and squamous cell carcinomas are skin cancers that are contained in the outermost layer of the skin, the epidermis. The cells on the topmost layer of skin are called squamous cells, which are constantly shedding and being replaced by basal cells, located in a lower layer of the epidermis. Basal and sqaumous cell cancers are most commonly developed from sun exposure and poor sun protection. They are found in areas such as the face, back of the neck, arms, ears, or hands. The most  common type of skin cancer is a basal cell carcinoma, a slow growing cancer that is minimally invasive and rarely spreads throughout the body. A squamous cell carcinoma is less likely but has a higher likelihood of spreading to other parts of the body because it is found in deeper layers of the skin.

The two main surgical procedures to treat these carcinomas are Mohs surgery and excisions. The Mohs procedure is practiced when there is a skin cancer present on visible areas of the face. Mohs is beneficial because it preserves as much healthy skin as possible and keeps scarring to a minimum. This treatment involves subsequently removing layers of skin that contain malignant cancer cells and immediately sending them to the lab for analysis of leftover tumor. If cancer cells are identified under the microscope, the doctor goes back in to remove another layer of the skin, and the process is repeated until there are no leftover cancer cells. Similar to removing a rotten chunk of an apple, the removed portion is tested for residual impurities. The process is repeated until the patient’s slides are all cleared, Dr. Aasi averaging between one to three stages per patient.

An excision surgery is performed when the skin cancer is located in more conservative areas of the body such as the back, chest, or abdomen. The procedure removes a larger portion of the skin and cuts deeper than Mohs procedure. The doctor incises around a predictable margin for the tumor and immediately sutures the incision without waiting for lab results. Then, the sample is sent to the lab and the team notifies the patient of the results in a few days.

The Middle: What I Learned from Watching Surgery

The first surgery I watched was a Mohs procedure on the outer cartilage of the ear. After the nurses numb the area by administering shots of lidocaine with epinephrine, Dr. Aasi enters and incises around the tumored area. She gently holds and lifts the thin layer of skin using a pair of tweezers. Next she makes systematic cuts under the lifted layer of skin and runs them smoothly up the incised area until the entire sample is cut loose. Dr. Aasi also makes two grid-like cuts along adjacent sides of the incision to orient the sample in relation to the patient’s body. These grid marks help her understand what she is seeing under the microscope. The practice seems routine, almost too easy for Dr. Aasi’s experienced hands. Her steady, composed form makes the evidently complex operation seem simple.

The nurses take care of most residual duties such cautery and pressure dressings between stages, while Dr. Aasi is usually out the door and already halfway to the lab before I can even turn toward the exit. After each stage, the clinic sends the sample of skin to pathology where Dr. Aasi sketches the shape of the sample and applies a different color dye to each edge. These preliminary duties help her visualize a general map of the sample under the microscope. By adding the blue, black, and red dyes, Dr. Aasi distinguishes top from bottom and left from right in relation to the sketch, which is always drawn in regard to the patient’s left shoulder. The pathologists flatten and cut the sample of skin into several slides that are put through an automatic dye machine and then arranged for the doctor to read.

The first time I observed Dr. Aasi viewing specimens under the microscope I was baffled at the speed at which she zipped through the slides and made calls to clear the patient. While all the cells looked like identical blobs to me, she was able to differentiate between  the misshapen island cells of a tumor and the sweat glands, hair follicles, nerves, and normal skin cells the body produces. Over time Dr.Aasi taught me how to distinguish the cluttered, island like appearance of cancer cells from the rest of the body’s creations. Usually colored darker than the surrounding areas, they show up in clusters, resembling nests of irregularly shaped cells. If any tumor is seen under the slide, Dr. Aasi determines which area of the original sample the tumor is in based on the grid marks and dye she placed on the specimen. Characteristic of Mohs, in subsequent stages Dr. Aasi removes skin only from areas where tumor is still present, preserving as much healthy skin as possible.

The Inside: The Lessons That Changed How I View Medicine

While Dr. Aasi operates on patients she often strikes up conversations about random yet intriguing topics. We find ourselves talking about how classy the Obama family is one minute and the next Dr. Aasi will be reminiscing her college days and how she actually had to go to the library and read a book to do research. These spur of the moment exchanges characterize my most valuable glimpses into Dr. Aasi’s life. She discloses stories about her career in medicine, ranging from her experiences as an attending, the hardships of adjusting to new hospitals, and some of the scariest moments she’s had in an operating room. These stories inspire through character, they mean something because they make the hospital come to life, and it’s stories like this I hope I’m able to tell someday.

Through my time at Stanford I learned so much more than I thought I would. Not just about the nature of dermatologic surgery, which proves to be a job for a doctor, artist, and perfectionist all in one, but also about the unforeseeable speed at which life moves and the pure joy that comes from being able to help people. From hearing the stories of hundreds of patients and watching the doctor cure their illnesses, I got a firsthand glance into the miracles of medicine. After witnessing the pain and suffering associated with cancer, I was moved by the resilience of patients faced with circumstances beyond their control. I was stirred by the selflessness of doctors and the amazed by the rhythm of hospital clinics. I learned more from this experience than could ever be written in a textbook, urging me to learn by facing a constant rollercoaster of emotions. But most importantly I learned to never forget sunscreen.