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

2 | Bunny Rabbits, Boston, and Babies

bunny rabbits, boston, and babies Never underestimate the capacity of a peripheral nerve to retain IV fluid. These are the words I hear in my head as I bend over a baby’s leg, straightening it, taping it down, and prepping it with Be­ ta­ dine swabs. This internal coach, the voice of my former chief of surgery, is neither random nor imagined . He had a way of tucking these instructive sound bites within the impressionable folds of a trainee’s brain—not necessarily a gentle process, but one that made them more memorable. Years later, his words remind me that structures that have the same size, color, and longitudinal orientation as veins may, in fact, be something else. They may be nerves or tendons, structures that have very different purposes than veins and are best left undisturbed in a baby’s leg. Like a kicker who lines up a field goal the same way for each attempt , I feel the femoral pulse in the baby’s groin and drop down a centimeter before making my quarter-inch incision directly over the presumed location of the saphenous vein. My habitual maneuvers don’t guarantee success, but surgeons, understanding that skill will only take you so far, carry the burden of superstition into each operation. They cling to ritual, performing each step of a procedure in the exact same sequence every time so that nothing important is skipped. I tease apart globules of subcutaneous fat with a needle-nose mosquito hemostat, the smallest clamp made, being careful not to ( 16 ) s m a l l stray into the translucent fibers of the thigh muscle underneath. The elusive thread of the saphenous vein runs the length of the leg starting just in front of the medial malleolus, the ankle bone, on the inside surface of the lower leg, where in thin patients you can see it and run your finger down its sinewy contour. The vein tracks up the lower leg straight up to the knee, then angles off through the thigh to the groin, where it dives into the deeper reservoir of the femoral vein. Decades from now, some heart surgeon somewhere might use this same vein to bypass the clogged and calcified coronary arteries of this patient. This could be the vein that sends her, in middle age, to a plastic surgeon to ream out unsightly swellings known as varicosities . This very vein might one day become inflamed, advancing to a painful case of phlebitis, and cause her to call in sick to work. But before those trials will ever have a chance to materialize, this premature infant, with fledgling lungs that require ventilator support, must grow up and mature into adulthood. She must first survive this hospitalization and the danger of having been introduced to the world as an incomplete human vulnerable to disease, infection, and disability. That means finding a vein. It sounds like a simple task: finding a vein and inserting an iv. It’s the kind of chore that surely someone other than a surgeon could perform. And that is the case for most adults who require an iv. But the veins of adults are garden hoses—bigger, obvious, thicker, and more durable compared to the fragile channels of premature infants. Getting an iv started in a tiny baby is not a given. It is a gift, acquired with skill, experience, and patience. There are times when the frontline nurses, nurse practitioners, and neonatologists have all tried and failed to get an iv started. The pediatric surgeon is then called in, the last resort, obliged to work where others have tread before on bruised arms and legs peppered with crusted-over needle sticks from failed attempts. A surgeon is trained to have the skills to delve deeper, cut beneath the skin, and find a vein when no one else can. bunny rabbits, boston, and babies ( 17 ) But that doesn’t mean it will be easy. “The ratio of congenital absence of the saphenous vein is inversely proportional to the experience of the surgeon,” leading pediatric surgeon Dr. Willis Potts once noted.1 In other words, a surgeon who couldn’t find the vein might be prone to blaming the failure on an anatomic anomaly rather than his own limited technical skill. Maybe the vein just wasn’t located where it was supposed to be. Potts made the statement in the 1950s, an era when...