Across The Red Line: Stories From The Surgical Life

14. Luck

14 Luck It’s been a long time since I found out about the surprising lack of correlation between a surgical job well done and a smooth, successful postoperative recovery. I remember as a resident, even, noticing that sometimes a beautiful operation performed by one of my heroes, one of the best, would end in bad result; either a major complication, or a major complication and death. On the other hand, I saw some none-too-well executed operations conclude with happy patients and what I thought was undeserved praise for their less-than-expert surgeons. What could explain this incongruity, this breach of the moral connection between effort and result? Well, I still don’t know and it still happens—not often, but frequently enough to make me think. I have not been an overly lucky surgeon, one who can relax and still get good results. I still feel that I have to try as hard as I can and that if I don’t, the patient and I will suffer. Even at what feels like full effort, bad things happen and I feel responsible. Then, too, every once in a while, I (and the patient) get very lucky. It is pleasing when that happens, but I feel a little guilty about it. Two patients tell this story themselves, Jonathan Tims and Reggie Richards. Jonathan Tims was betrayed from within. He was a fit 51-year-old oil company executive with a perfectly functioning body except for one organ: his intestine. For ten years Tims had argued with his colon, the lining of which 138 kept leaving him in torrents of diarrhea. He had learned to accommodate to the symptoms of sudden and cataclysmic rectal bleeding, weakness and fluid loss. He had heard, really heard, the admonition of his doctor, who told him that his disease, ulcerative colitis, held more than troublesome symptoms in store; his diagnosis was associated with a prohibitively high incidence of cancer. Finally, Jon consented to an operation to remove his colon. He eschewed a complicated operation which would reconstruct his anus and leave him with a normal, albeit frequent, way to go to the bathroom. He chose a simpler operation that would leave him with an ileostomy—a “bag.” Jon had been admitted to the hospital last summer for the operation, but his debilitated state required a few weeks of intravenous feedings, “hyperalimentation,” to build him up for the operation. To do that, a catheter was inserted through his neck into a “central vein”—in fact, the vein which drains directly into the heart: the superior vena cava. But last summer, complications set in. The catheter became infected and Jon developed a high fever and other obvious signs of infection. The catheter was removed, but the fevers continued. The infection had jumped off the catheter and taken hold somewhere in Jon’s body. Ultimately the site was discovered. Jon’s heart valves harbored the infection. Little seeds of bacteria clung to his valves as they opened and closed 84 times a minute. You could hear the murmur with a stethoscope. Six weeks of intravenous antibiotics were prescribed and Jon consented. He wanted to rid his heart valve leaflets of the second Trojan horse. First his colon, now his heart was the enemy inside him. In time the infection was corralled and, miraculously, Tims’s colon symptoms abated coincidentally, as if he had Luck 139 been compensated for his heart’s misfortune. Jonathan Tims was discharged and went home, chastened by his own frailty and that of his heart and colon. In late fall, Jon’s symptoms became worse. Despite his memories of last summer, he agreed to be admitted for his overdue operation. When I first met him, Jonathan Tims was the picture of a confident businessman momentarily sidetracked into the hospital. He asked pertinent questions and was very cordial . But in his affect now there was a hint of fear, for Jonathan had learned things last summer about the slender thread of health. He knew about fragility. He knew about bad luck. “Jon,” I said, “I will remove the entire colon and rectum ; your bottom will be sewn shut. I’ll bring your small intestine out to the skin, where it will empty into a bag.” “It’s strange,” he said, “how the colon can be so sick and yet the contiguous small intestine is free of disease.” I talked to...