Small: Life and Death on the Front Lines of Pediatric Surgery

1 | The Thread of Life

the thread of life “Stitch,” I say to the scrub nurse. I hold out my hand, waiting. Instead of keeping up with me, the next suture ready to slap into my palm, she’s hit a snag trying to pull the suture out of the package and load the needle in the gold-handled needle holder. I wish I could reach across the instrument tray and do it myself, but I can’t move. If I look away, I’ll lose my place, and that will only delay me further. I’m focusing on an area no bigger than a postage stamp through a pair of surgical loupes that magnify my limited view. I can see the exact spot where the next stitch needs to go, between two gaping edges of intestine, the width of a matchstick. “Let’s go,” I say. “Let’s get this finished.” I know I seem impatient, but it is not because I’m in a hurry to get to something else. My only focus at the moment is on this baby, Clare. I know that every moment she is under the drapes on the operating room table her life is at risk. Born eight weeks early, she weighs only four pounds. A breathing tube no bigger than a straw is keeping her alive during this operation. The correct position of this tube, inside her trachea, is measured in millimeters . If it is accidentally pushed in or pulled out, even a minuscule amount, her lungs will fail to expand and deflate and an alarm will go off. Any interruption in ventilation will cause us to stop operating . The anesthesiologist will have to check the breathing tube and adjust it as needed. If the tube completely dislodges, the oxygen level in the bloodstream will plummet and within seconds ( 2 ) s m a l l the baby’s heart, deprived of oxygen, will start to slow dangerously . When that happens, the baby will be close to cardiac arrest. And if her heart does stop beating and normal blood circulation ceases, not only will this interrupt the operation, it could end it before we finish repairing the congenital malformation we came here to fix. We will have to staple everything closed and get out as quickly as possible. In other words, a complication like this can result in disaster, a nightmare for surgeon and patient alike, and I had seen it before. Three decades ago, when I was training to be a surgeon, I was assisting in an operation to repair bilateral inguinal (groin) hernias, persistent openings between the lining of the abdomen and the scrotum, in a premature baby boy with chronic lung disease. This is normally a straightforward repair that requires making a small incision on either side of the lower abdomen and locating and tying off a tissue sac. But on this particular morning, when the pediatric surgeon and I were about to finish and close the skin, the breathing tube slipped down too far, into the right-side bronchus, so that only the right lung was being ventilated. Within seconds, the infant’s oxygen level dropped, his heart rate slowed, and the anesthesiologist disconnected the ventilator and started bagging the baby by hand to inflate his scarred and stiffened lungs. In his excitement to correct the problem, he used too much force. The pressure blew out both lungs like they were dime-store balloons, rendering them temporarily useless. The chest filled up with air, which compressed the lungs and kept them from expanding at all. The surgeon and I pulled off the drapes and started cpr using two fingers, rather than the weight of an entire hand, to compress the undersized newborn’s heart. Then we incised both sides of the chest with our scalpels and slid small drainage tubes between ribs as thin and pliable as Q‑tips. Within seconds, the air drained out of the chest cavity and the tiny lungs reexpanded. The heart the thread of life ( 3 ) started beating again, and the baby stabilized. We prepped the field and finished closing. “That’s the first time I’ve ever done bilateral hernias and bilateral chest tubes at the same time,” the surgeon said. A nervous laugh spilled out to punctuate his relief. Everyone in the room knew how close we had come to losing that baby when no one was expecting it. Hernia operations are not usually considered...