Complications: A Surgeon's Notes on an Imperfect Science

By the time Lee arrived in our intensive care unit, his breathing was a buzzing, reedy stridor. You could hear it three beds away. The scientific literature is unequivocal about this situation: it is deadly dangerous. Just laying him down could cause the tumor to cut off the remainder of his airway. Giving him sedatives or anesthesia could do the same. Surgery to remove the tumor is impossible. Chemotherapy, however, is known to shrink some of these tumors over the course of a few days. The question was how to buy the child time to find out. It wasn’t clear he’d last the night.

We had two nurses, an anesthesiologist, a pediatric surgery junior fellow, and three residents at the bedside, myself included; the senior pediatric surgeon was on his cell phone, driving in from home; an oncologist was on page. One nurse propped Lee up on pillows to make sure he was as upright as he could be. The other put an oxygen mask on his face and hooked up monitors tracking his vital signs. The boy’s eyes were wide and worried, and his breathing was about twice too fast. His family was still far away, having to travel by ground. But he remained sweetly brave, as children do more often than you’d expect.

My first instinct was that the anesthesiologist should put a stiff breathing tube into the boy’s airway to fix it open before the tumor closed in. But the anesthesiologist thought this was nuts. She’d have to put the tube in without good sedation, with the kid sitting up, no less. And the tumor extended far along the airway. She wasn’t convinced she could reach a tube past it easily enough.

The surgical fellow proposed another idea: if we put a catheter into the boy’s right chest and drained off the fluid filling it, the tumor would tilt away from the left lung. On the phone, however, the senior surgeon was concerned that this could worsen matters. Once you have unsettled a boulder, can you honestly say which way it will roll? No one was thinking of any better options, however. So ultimately he said to go ahead.

I explained to Lee what we were going to do as simply as I could. I doubt he understood. That may have been just as well. After we’d gathered all the supplies we needed, two of us held Lee tight, and another injected a local anesthetic between his ribs, then made a slit with a knife and pushed a foot-and-a-half-long rubber catheter in. Bloody fluid poured out of the tube by the quart, and for a moment I was afraid we’d done something terrible. But as it turned out, we’d done more good than we could have hoped for. The tumor shifted rightward and somehow the airways to both lungs opened up. Instantly, Lee’s breathing became easier and quiet. After watching him a few minutes, so did ours.

Not until later did I wonder about our choice. It was little more than a guess about what to do—a stab in the dark, almost literally. We had no backup plan should disaster have occurred. And when I looked up reports of similar cases at the library afterward, I learned that other options did in fact exist. The safest thing, apparently, would have been to put him on a heart-lung bypass pump like the kind used during cardiac surgery, or at least to have one on standby. Talking with the others about it, though, I found that no one regretted a thing. Lee survived. That was what mattered. And his chemotherapy was now under way. Testing of the fluid showed the tumor to be a lymphoma. The oncologist told me that this gave Lee a better than 70 percent chance of total cure.

These are the moments in which medicine actually happens. And it is in these moments that this book takes place—the moments in which we can see and begin to think about the workings of things as they are. We look for medicine to be an orderly field of knowledge and procedure. But it is not. It is an imperfect science, an enterprise of constantly changing knowledge, uncertain information, fallible individuals, and at the same time lives on the line. There is science in what we do, yes, but also habit, intuition, and sometimes plain old guessing. The gap between what we know and what we aim for persists. And this gap complicates everything we do.

I am a surgical resident, very nearly at the end of my eight years of training in general surgery, and this book arises from the intensity of that experience. At other times I have been a laboratory scientist, a public health researcher, a student of philosophy and ethics, and a health policy adviser in government. I am also a son of two doctors, a husband, and a parent. I have attempted to bring all of these perspectives to bear on what I have written here. But more than anything, this book comes from what I have encountered and witnessed in the day-to-day caring for people. A resident has a distinctive vantage on medicine. You are an insider, seeing everything and a part of everything; yet at the same time you see it anew.

In some way, it may be in the nature of surgery itself to want to come to grips with the uncertainties and dilemmas of practical medicine. Surgery has become as high tech as medicine gets, but the best surgeons retain a deep recognition of the limitations of both science and human skill. Yet still they must act decisively.

The book’s title, Complications, comes not just from the unexpected turns that can result in medicine but also, and more fundamentally, from my concern with the larger uncertainties and dilemmas that underlie what we do. This is the medicine that one cannot find explained in textbooks but that has puzzled me, sometimes troubled me, sometimes amazed me, as I’ve joined the profession’s ranks. I have divided the book into three sections. The first examines the fallibility of doctors, asking, among other things, how mistakes happen, how a novice learns to wield a knife, what a good doctor is, how it is that one could go bad. The second focuses on mysteries and unknowns of medicine and the struggles with what to do about them; these are the stories of an architect with incapacitating back pain in whom no physical explanation could be found, a young woman with an awful nausea that would not go away, a television newscaster whose blushing became so inexplicably severe that she could no longer function in her job. The third and final section then centers on uncertainty itself. For what seems most vital and interesting is not how much we in medicine know but how much we don’t—and how we might grapple with that ignorance more wisely.

Throughout I’ve sought to show not just the ideas but also the people in the middle of it all—the patients and doctors alike. In the end, it is practical, everyday medicine that most interests me—what happens when the simplicities of science come up against the complexities of individual lives. As pervasive as medicine has become in modern life, it remains mostly hidden and often misunderstood. We have taken it to be both more perfect than it is and less extraordinary than it can be.

Education of a Knife

The patient needed a central line. “Here’s your chance,” S., the chief resident, said. I had never done one before. “Get set up and then page me when you’re ready to start.”

It was my fourth week in surgical training. The pockets of my short white coat bulged with patient printouts, laminated cards with instructions for doing CPR and using the dictation system, two surgical handbooks, a stethoscope, wound-dressing supplies, meal tickets, a penlight, scissors, and about a buck in loose change. As I headed up the stairs to the patient’s floor, I rattled.

This will be good, I tried to tell myself: my first real procedure. My patient—fiftyish, stout, taciturn—was recovering from abdominal surgery he’d had about a week before. His bowel function hadn’t yet returned, leaving him unable to eat. I explained to him that he needed intravenous nutrition and that this required a “special line” that would go into his chest. I said that I would put the line in him while he was in his bed, and that it would involve my laying him out flat, numbing up a spot on his chest with local anesthetic, and then threading the line in. I did not say that the line was eight inches long and would go into his vena cava, the main blood vessel to his heart. Nor did I say how tricky the procedure would be. There were “slight risks” involved, I said, such as bleeding or lung collapse; in experienced hands, problems of this sort occur in fewer than one case in a hundred.

But, of course, mine were not experienced hands. And the disasters I knew about weighed on my mind: the woman who had died from massive bleeding when a resident lacerated her vena cava; the man who had had to have his chest opened because a resident lost hold of the wire inside the line which then floated down to the patient’s heart; the man who had had a cardiac arrest when the procedure put him into ventricular fibrillation. But I said nothing of such things when I asked my patient’s permission to do his line. And he said, “OK,” I could go ahead.

I had seen S. do two central lines; one was the day before, and I’d attended to every step. I watched how she set out her instruments and laid down her patient and put a rolled towel between his shoulder blades to make his chest arch out. I watched how she swabbed his chest with antiseptic, injected lidocaine, which is a local anesthetic, and then, in full sterile garb, punctured his chest near his clavicle with a fat three-inch needle on a syringe. The patient didn’t even flinch. S. told me how to avoid hitting the lung with the needle (“Go in at a steep angle; stay right under the clavicle”), and how to find the subclavian vein, a branch to the vena cava lying atop the lung near its apex (“Go in at a steep angle; stay right under the clavicle”). She pushed the needle in almost all the way. She drew back on the syringe. And she was in. You knew because the syringe filled with maroon blood. (“If it’s bright red, you’ve hit an artery,” she said. “That’s not good.”)

Once you have the tip of this needle poking in the vein, you have to widen the hole in the vein wall, fit the catheter in, and thread it in the right direction—down to the heart rather than up to the brain—all without tearing through vessels, lung, or anything else. To do this, S. explained, you start by getting a guidewire in place. She pulled the syringe off, leaving the needle in place. Blood flowed out. She picked up a two-foot-long twenty-gauge wire that looked like the steel D string of an electric guitar, and passed nearly its full length through the needle’s bore, into the vein, and onward toward the vena cava. “Never force it in,” she warned, “and never ever let go of it.” A string of rapid heartbeats fired off on the cardiac monitor, and she quickly pulled the wire back an inch. It had poked into the heart, causing momentary fibrillation. “Guess we’re in the right place,” she said to me quietly. Then to the patient: “You’re doing great. Only a couple minutes now.” She pulled the needle out over the wire and replaced it with a bullet of thick, stiff plastic, which she pushed in tight to widen the vein opening. She then removed this dilator and threaded the central line—a spaghetti-thick, yellow, flexible plastic tube—over the wire until it was all the way in. Now she could remove the wire. She flushed the line with a heparin solution and sutured it to his chest. And that was it.

I had seen the procedure done. Now it was my turn to try. I set about gathering the supplies—a central-line kit, gloves, gown, cap, mask, lidocaine—and that alone took me forever. When I finally had the stuff together, I stopped outside my patient’s door and just stood there staring, silently trying to recall the steps. They remained frustratingly hazy. But I couldn’t put it off any longer. I had a page-long list of other things to get done: Mrs. A needed to be discharged; Mr. B needed an abdominal ultrasound arranged; Mrs. C needed her skin staples removed. . . . And every fifteen minutes or so I was getting paged with more tasks—Mr. X was nauseated and needed to be seen; Miss Y’s family was here and needed “someone” to talk to them; Mr. Z needed a laxative. I took a deep breath, put on my best don’t-worry-I-know-what-I’m-doing look, and went in to do the line.

I placed the supplies on a bedside table, untied the patient’s gown behind his neck, and laid him down flat on the mattress, with his chest bare and his arms at his sides. I flipped on a fluorescent overhead light and raised his bed to my height. I paged S. to come. I put on my gown and gloves and, on a sterile tray, laid out the central line, guidewire, and other materials from the kit the way I remembered S. doing it. I drew up five cc’s of lidocaine in a syringe, soaked two sponge-sticks in the yellow-brown Betadine antiseptic solution, and opened up the suture packaging. I was good to go.

S. arrived. “What’s his platelet count?”

My stomach knotted. I hadn’t checked. That was bad: too low and he could have a serious bleed from the procedure. She went to check a computer. The count was acceptable.

Chastened, I started swabbing his chest with the sponge-sticks. “Got the shoulder roll underneath him?” S. asked. Well, no. I had forgotten this, too. The patient gave me a look. S., saying nothing, got a towel, rolled it up, and slipped it under his back for me. I finished applying the antiseptic and then draped him so only his right upper chest was exposed. He squirmed a bit beneath the drapes. S. now inspected my tray. I girded myself.

“Where’s the extra syringe for flushing the line when it’s in?” Damn. She went out and got it.

I felt for landmarks on the patient’s chest. Here? I asked with my eyes, not wanting to undermine my patient’s confidence any further. She nodded. I numbed the spot with lidocaine. (“You’ll feel a stick and a burn now, sir.”) Next, I took the three-inch needle in hand and poked it through the skin. I advanced it slowly and uncertainly, a few millimeters at a time, afraid to plunge it into something bad. This is a big goddam needle, I kept thinking. I couldn’t believe I was sticking it into someone’s chest. I concentrated on maintaining a steep angle of entry, but kept spearing his clavicle instead of slipping beneath it.

“Ow!” he shouted.

“Sorry,” I said. S. signaled with a kind of surfing hand gesture to go underneath the clavicle. This time it did. I drew back on the syringe. Nothing. She pointed deeper. I went in deeper. Nothing. I took the needle out, flushed out some bits of tissue clogging it, and tried again.

“Ow!”

Too superficial again. I found my way underneath the clavicle once more. I drew the syringe back. Still nothing. He’s too obese, I thought to myself. S. slipped on gloves and a gown. “How about I have a look,” she said. I handed her the needle and stepped aside. She plunged the needle in, drew back on the syringe, and, just like that, she was in. “We’ll be done shortly,” she told the patient. I felt utterly inept.

She let me continue with the next steps, which I bumbled through. I didn’t realize how long and floppy the guidewire was until I pulled the coil out of its plastic sleeve, and, putting one end of it into the patient, I very nearly let the other touch his unsterile bed-sheet. I forgot about the dilating step until she reminded me. Then, when I put in the dilator, I didn’t push quite hard enough, and it was really S. who pushed it all the way in. Finally we got the line in, flushed it, and sutured it in place.

Outside the room, S. said that I could be less tentative the next time, but that I shouldn’t worry too much about how things had gone. “You’ll get it,” she said. “It just takes practice.” I wasn’t so sure. The procedure remained wholly mysterious to me. And I could not get over the idea of jabbing a needle so deeply and blindly into someone’s chest. I awaited the X-ray afterward with trepidation. But it came back fine: I had not injured the lung and the line was in the right place.

Not everyone appreciates the attractions of surgery. When you are a medical student in the operating room for the first time, and you see the surgeon press the scalpel to someone’s body and open it like fruit, you either shudder in horror or gape in awe. I gaped. It was not just the blood and guts that enthralled me. It was the idea that a mere person would have the confidence to wield that scalpel in the first place.

There is a saying about surgeons, meant as a reproof: “Sometimes wrong; never in doubt.” But this seemed to me their strength. Every day, surgeons are faced with uncertainties. Information is inadequate; the science is ambiguous; one’s knowledge and abilities are never perfect. Even with the simplest operation, it cannot be taken for granted that a patient will come through better off—or even alive. Standing at the table my first time, I wondered how the surgeon knew that he would do this patient good, that all the steps would go as planned, that bleeding would be controlled and infection would not take hold and organs would not be injured. He didn’t, of course. But still he cut.

Later, while still a student, I was allowed to make an incision myself. The surgeon drew a six-inch dotted line with a marking pen across a sleeping patient’s abdomen and then, to my surprise, had the nurse hand me the knife. It was, I remember, still warm from the sterilizing autoclave. The surgeon had me stretch the skin taut with the thumb and forefinger of my free hand. He told me to make one smooth slice down to the fat. I put the belly of the blade to the skin and cut. The experience was odd and addictive, mixing exhilaration from the calculated violence of the act, anxiety about getting it right, and a righteous faith that it was somehow good for the person. There was also the slightly nauseating feeling of finding that it took more force than I’d realized. (Skin is thick and springy, and on my first pass I did not go nearly deep enough; I had to cut twice to get through.) The moment made me want to be a surgeon—not to be an amateur handed the knife for a brief moment, but someone with the confidence to proceed as if it were routine.

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.