Sunday, January 25, 2009
The Joy of the Master
One of the must-have textbooks for a young surgical resident is Mastery of Surgery. It's a two volume tome detailing the rationale and methods of surgical technique for pretty much every operation we do. Everything from the old Halsteadian radical mastectomy to the laparoscopic Heller myotomy is in that baby. It's a wonderful book. I still peruse through it the night before big cases. But I always hated the title when I was a younger resident. Mastery of surgery. It sounded so typically pompous and bombastic; what one would expect from staid, formalistic surgical academia. The word "mastery" nagged at me, hinted at something overwrought and unattainable. How could one ever think it would be possible to master all the vagaries and intricacies of general surgery?
But my understanding of what it meant to master a profession was woefully inadequate. It isn't about memorizing the steps to a bunch of operations. What I didn't understand was that it was the vagaries and intricacies themselves that separate a true master from the journeyman. You give an apprentice a nice piece of wood and first class tools and the proper instructions, there's a good chance he'll be able to pound out a decent bookcase for you. It will be sturdy and durable and it won't draw negative attention to itself. But a master carpenter can take a bundle of scrap wood and some shabby blunted tools and he'll create a work of art, a centerpiece that guests ask about when they enter your home. Excellence under adverse conditions. A master surgeon is similar in this regard.
I had the privilege of working with such a master surgeon in Chicago as a resident at Rush University Medical Center. Dr. Alexander Doolas was in the latter stages of his career when I was there but he was still one of the busiest surgeons in the hospital. Dr. Doolas is cut from that old school cloth of pure bad ass, no holds barred, no nonsense, work all night, take no excuses, knows more than everyone and isn't afraid to tell you kind of surgeon that used to rule the roosts at big academic centers. (Surgery has now evolved into its kinder and gentler phase of development with work hour reform and the civilizing influence of more women entering the field.) Dr Doolas is about 5'6" and his physique is cut like one of those Bulgarian power lifters. He's always tanned and well dressed outside the OR with his hair immaculately slicked back like Al Pacino in Scent of a Woman. Merely standing in his presence as an intern was terrifying enough. But then he'd open his mouth and this alpha-male, heavily-Greek accented deep baritone would come growling out and you'd literally start dropping pens and papers and maybe even slightly losing control of your sphincter mechanism if you'd done something wrong or forgot a crucial detail. He scared the hell out of me that first year. He was notorious for calling interns randomly in the middle of the night for updates on his ICU patients. The page would come in from an outside line and you'd sprint down to the unit to review the bedside flowsheet before calling it back. And you couldn't make numbers up because Dr. Doolas would often first call the ICU nurse to get the actual answers and compare it with what you told him. So we all ended up hanging out down in the ICU most call nights until after midnight, just in case the old man wanted an update. His big thing was fluids and electrolytes. The man lived for sodium concentrations and potassium losses in bile and the exact chloride composition of pancreatic secretions and urine outputs and the precise balancing of fluid intake versus fluid losses. After Whipples he put in G-tubes (gastrostomy tube) and decompressive J-tubes (jejunostomy) and feeding J-tubes and an NG and you needed to know how much was coming out of each and what it looked and even what it smelled like. He thought he could smell when there was a pancreatic leak. You'd see him digging around on a post-op belly with his bare hands sniffing the end of the drains to determine his next move. Patients with delayed gastric emptying after a Whipple can often lose a lot of water and sodium via NG and G-tube decompression. He sometimes liked to replace those losses not with saline infusions but with the actual fluid itself. So nurses would have to collect the G-tube and decompressive J-tube outputs, put it in a plastic bowl on ice and then refeed it via the feeding J-tube every shift. It was gross but it made sense. It was perfect actually.
On rounds, it was the Dr. Doolas show. He had this charismatic, disarming, eccentrically charming bedside manner that patients just ate up. They loved him. He projected pure confidence and rightness of action. He could walk into an old man's room who'd had a left colectomy and Dr Doolas would pontificate for twenty minutes on how the Persians invaded Greece unprovoked and how they got their comeuppance, and then maybe at the end, right before abruptly leaving, tell the patient that he needed to start eating more potatoes and the patient would nod enthusuastically, as if the Holy Ghost Himself had paid him a visit. He also liked to speak in metaphors. I remember this high maintenance suburban patient who had had a pancreatic resection and she had a thousand questions for Dr Doolas about what was happening and why he was doing certain things. You could tell he was getting annoyed. He took off his glasses (always a sign of something legendary about to happen), started gnawing on the tip, and he held up his hand and that deep voice rolled out at her like a surging wave, "Listen! When you get on an airplane and you're flying to Milwaukee to see your cousin Angelo, do you get up out of your seat and go knocking on the pilot's door and ask him what that knob is and why that light is flashing and how's come the dashboard is beeping like that? Do you? No. You don't. So you let me fly this plane." Some of his metaphors, however, tended to be seemingly ad libbed and barely coherent. You could ask him why he wanted to restrict a patient to scrambled eggs without the yolks, red beans, and unbuttered toast and you were liable to get an answer along the lines of: "Listen. When you get on the bus and you want to get to Evanston there's always an old lady sitting next to you asking if you know where her recipe book is and meanwhile there might be an elephant at the next stoplight but you don't know you so you have to count backwards from 57 by threes until you get to the second prime number and then it's like when the Inuits crossed the Bering Strait and it all becomes obvious. You got it?" And he'd stare at you like you were the stupidest person on earth, your mouth agape, wide eyed, not knowing what in the hell to say, and he'd finally just shake his head and walk away.
In the OR Dr. Doolas was legendary. He was famous for the two hour Whipple. The 20 minute colectomy. He'd hunch over the table, his giant bald head inches from the pancreas, headlamp illuminating an orb of intimate anatomy, and everything he did, every move was filled with purpose. He didn't move fast, he just didn't waste any action. Every maneuver served the purpose of advancing the operation toward its logical conclusion. There was no dicking around, no hemming and hawing, no tentative picking and pawing at tissues. He knew where he was at all times, where he needed to go, and what was necessary to facillitate that end. He didn't let the residents do much unless you were a chief and then, only if he liked you. But operating with Dr. Doolas was beside the point. It was enough to just watch the man in action. Two cases come to mind.
The first was a lady who had been referred to Dr Doolas from an outside hospital. The poor lady had been suffering from an enterocutaneous fistula for over a year. She'd had multiple operations and she hadn't been eating and she just seemed broken and defeated. Green bile leaked from her fistula near the belly button. Scars criss-crossed her abdomen. She looked gaunt and emaciated. Everyone else had given up on her. Dr. Doolas reviewed her scans and xrays and put her on the OR schedule for the next day. Under anesthesia he made a single incision through the midline scar and it soon became apparent we were dealing with a frozen abdomen. A patient who has had peritonitis and multiple operations can develop so much scar tissue that all tissue planes are obliterated; it's as if someone has poured cement between the loops of bowel. There's no free space. Everything is socked in, frozen in place. Every move you make is fraught with hazard. It's easy in these situations to do more harm than good. It's a situation that most surgeons try to avoid and that's why a lot of them end up ultimately with surgeons like Dr Doolas. After the initial incision, Dr. Doolas asked for a hemostat. For the next 60 minutes that's all he used. I watched him wield that blunt tip of the hemostat like chisel, chipping and scraping and carving his way through the scar and granulation tissue until he had isolated the loop of bowel involved in the fistula and separated it from the abdominal wall. It was like watching Rodin create a masterpiece out of a block of granite. In ninety minutes he completed what would have taken any other surgeon 6-8 hours. The patient went home in 4 days, happier than she had been in over a year.
The other case was a thin guy who had had an esophagectomy with a gastric pull-up a number of years ago at an outside institution. He then developed a stricture at the esophagogastrostomy anastomosis in the neck. A previous revision had re-strictured. Multiple attempts at balloon dilatation had failed. Now the man could not swallow even a glass of water. He was dependent on a feeding jejunostomy tube for nutrition. But he missed eating. He missed being able to cut up a perfectly cooked filet, chewing, savoring the juices, the act of swallowing. He wanted to experience it again. No matter what. Telling him no would have been entirely reasonable. He was living at home, surviving, getting by. There was no emergent rationale for further intervention other than the patient's consuming desire to eat again. Dr. Doolas was his last hope. No one else would take the case.
The day of the operation, Dr. Doolas was in one of his happy moods, razzing everyone, laughing easily, seemingly unperturbed by daunting task at hand. Any redo surgery is tricky and trying to revise an anastomosis in the neck for the second time is especially perilous. The neck is a small, contained space and important nearby structures like the recurrent laryngeal nerve and the carotid sheath are at risk of injury. It's a veritable hornet's nest of danger. But once again I watched Dr. Doolas use just a scalpel and a dissecting clamp to carve through dense scar tissue until, miraculously, the striated meaty fibers of the proximal esophagus appeared. From there, he worked his way down to the old anastomosis. Once eveything was dissected out he looked over at me, eyes glinting, and he tossed his head back and laughed, a deep hearty laugh, a guttural guffaw, a sonorous, soulful, Count Dracula sort of laugh from the depths of his being. His hands were momentarily at rest. The moment lingered. And then he started again. Ten minutes later he'd resected the stricture and created a widely patent new end to end anastomosis. The entire case took about 45 minutes. The patient was eating a hamburger three days later.
A master at work. All I did was run the sucker and tie some knots but I learned more from those two cases than in any operation where an attending allowed me to stumble my way through the maneuvers. Just watching. Seeing things the way Dr. Doolas saw them. The sense of undauntedness that he brought to a case. The confidence. The experience and knowledge. The creativity and vision. But I think there was something else, something you can't teach, maybe the most important thing. And it was all contained in that simple baritone laugh, his head tilted back, eyes slightly closed. It was the laugh of pure joy. For in that one brief moment the true master of surgery realizes a rare perfection, the uniqueness of his talents that have allowed him alone to actualize the healing of a complicated patient. There may not be a happier feeling in the world for those chosen few. Without that innate sense of joy, real unadulterated child-like joy, true mastery is unattainable no matter how many books you read or where you train or how many Whipples you watch.....