Across The Red Line: Stories From The Surgical Life

6. Hanging

6 Hanging I don’t care what they might tell you, any surgeon feels remorse and guilt when things turn out badly. Even if I have done the best I know how, a patient not prospering after a big operation takes over my life. In fact, I can say that each patient, from the time I make the incision until they are discharged from the hospital, fit and recovered, occupies a space at the back of my mind. I am on tenterhooks , sometimes more, sometimes less, about the outcome . Surgeons who tell you that once they have finished the operation, it’s “up to God,” are just suppressing their direct connection with the patient. Because I do cancer work, there is a special and difficult irony. Cancer usually doesn’t hurt. There may be some bleeding or some weight loss or a lump, but for the most part it is not like appendicitis ; the patient does not wake up at night twisted by sudden pain. So the cancer patient feels okay. Not great, but okay. Then I make the incision and then they hurt. They may know intellectually that they needed to be operated on, but they hurt more after I “help” them than before . I am always aware that mine is an act of controlled violence. And when there is unpredicted complication, or worse, death, it feels terrible. It feels like guilt and regret mixed together with a lonely isolation from everybody in the world who is not a surgeon with similar troubles. Right now, I am sweating it out. I had planned the operation , discussed it with the patient, his family, and the residents. Then we did it. Things went well during the 57 procedure. It was difficult, but I felt sure-handed and I had not had that fear that comes when I do not know if I can get it done or if I should even be trying to get it done. No; things went well in the operating room. When an operation is smooth, when no undue blood is lost, when the case is done with dispatch and no fumbling about, then the postoperative period is usually straightforward . I suspect that surgeons who refer to this situation as a “benign post-op course” have never been operated on themselves, because if they had, “benign” is one of the last words they would choose to describe the five to ten days in the hospital which follow a major operation. Although difficult and uncomfortable for the patient, the surgeon, who sees this all of the time, affects an attitude which is confident and reassuring: “This pain is normal, keep working on walking and doing your breathing exercises.” It is understandable that surgeons tend to spend remarkably little time with patients right after an operation. It is almost as if we do not want to see the physical and emotional agony we have caused. It is one thing to incise the chest of an anesthetized patient. It is quite another to see him gasp for breath, holding his incision, struggling to cough, while he looks at you with wide round eyes too polite and frightened to say: “What the hell have you done to me?” We all, I guess, want to keep our distance from that accusatory stare. So, if things are going well, the interaction is short. Removed just a necessary bit, it feels not great but okay to reassure the hurting patient when the pain and soreness and fatigue appear within normal limits. Patients have a wide variety of responses to pain. Some are quite stoic and others less so. In time I have developed a sense about pain 58 Chapter Six and I, like other physicians with a few years under their belts, now give more narcotics more liberally than I did as a righteous youth fearful of drug addiction and overdosage (both very uncommon in the average patient population). But right now, something is not right. Each day I walk into Frank Mendez’s room and we perform a 10-minute ritual: This 56-year-old man recovering from a colon cancer operation smiles wanly. “I think I am better,” he says. I note that there is no fever. His white blood cell count, a rise in which would signal infection, is normal. But the drainage from the tube in his stomach is high. Usually, as the intestinal tract begins to function...