Sustenance

In the fall of 1985, I was a surgery intern at a busy inner-city hospital. Already seasoned by a few months of training, I felt somewhat accustomed to long work hours, tense clinical situations, and regular exposure to human suffering. If survival was the goal, I seemed part-way there: I was still standing, even if many patients, through no obvious fault of mine, were not.

This was a unique time in medicine. Discoveries in laboratory and radiologic testing were occurring. A new understanding of human biology and physiology was emerging. Clinicians could make a difference in people’s lives, not just as compassionate bystanders but was informed actors, interveners. Lives could be saved, at least temporarily, through emergency procedures, dramatic surgical interventions, and new pharmaceuticals.

Or so many of us thought.

I was working on the vascular surgical service. An extremely busy team, we cared for people with all sorts of blockages in blood vessels. Whether due to chronic conditions such as diabetes, traumatic injuries, or a host of other causes, arteries, large and small, can become obstructed, limiting their ability to bring oxygenated blood to the range of tissue and organs in the human body that needs a routine supply of it. New techniques had been developed to help open clogged vessels, or bypass them with grafts of vein from other body locations. Once a blood flow could be re-established, or even minimally improved, cells and tissues starved of nutrients could recover. And patients’ symptoms, which often included severe pain, could be alleviated.

This was not a time when regulatory agencies monitored residency work hours. As an intern, I was often on-call every other night. That meant that I started rounds as early as four in the morning, worked until the following evening, and then, after whatever amount of sleep was possible, returned at four the next morning. Forty hours of sleepless duty (unless I was seated in a mid-day teaching rounds – during which it was fairly impossible to stay fully conscious), followed by eight hours of fitful shut-eye. That was the cycle. I learned to live on sandwiches, Cream of Wheat, crackers, and diet Pepsi. Lots of diet Pepsi. Plus whatever sleep and exercise was possible.

I am not complaining; despite the rigor, it felt good to be connected to something with purpose. I believed that I was part of something worthwhile. The struggle was not without meaning.

A surgical intern’s role is not glamorous. While I did have my share of dramatic intervention moments, most of the time I was charged with the more mundane, yet vital, tasks of preparing people for surgery or post-surgical discharge. It was common to admit fifteen people to the hospital the night before their surgeries, help assure they were properly ready for their procedures, round on them the evening after their surgeries, and help discharge them the next or a subsequent morning as indicated. As interns, we did the histories and physical exams, wrote the admissions orders, drew the labs, placed the peripheral iv’s (or larger central venous catheters), responded to routine questions and emergencies, stood in the operating room to hold retractors, and then reversed the process after the operations. It was anything but dull. The hours flew by. Sleep while on-call was little more than a head briefly cradled in an arm on a nursing station counter. Yet that brief cradle, even if only five minutes long, was always welcome.

Elective surgeries on the vascular service took place in multiple operating rooms on a regular schedule. I don’t remember the details. As interns, we worked hard to get people medically and surgically ready for their procedures. Often, we would temporarily “scrub out” of a surgery to check on someone or address an issue while the surgical attending staff and more senior residents and fellows remained in the operating room. They had all been interns. We understood that next year, or in the years that followed that, other junior physicians would stand in our shoes. So we just kept going. We tried not to think too far ahead.

One day, following a particularly busy night, I was standing at a patient’s side in one of the hospital’s many operating rooms. It was, I think, mid-afternoon. Who knows when I had last eaten. What I do recall is that I was relieved this was the last scheduled case of the day. It was a fairly simple one: a trans-metatarsal amputation. Unfortunately, the blood supply to the patient’s toes and distal half of his foot was unable to be repaired. The tissue for that area was dying. We were therefore removing the portion of his foot that could not be saved.

“Here you go.” The lead surgeon, a senior fellow who was specializing in vascular surgery, handed me the scalpel. “This is your case,” he said.

I think I had admitted this patient. But I had admitted so many patients the previous night that the details of this person were a blur. Interns were not often asked to take the lead in the operating room. We did everything from occasional first assist duties to standing with one hand on a sterile retractor holding some tissue or organ we could not see, with finger, hand, and forearm muscles that often fatigued and cramped. It was usually the latter. It was almost never the person with the scalpel.

We proceeded. Somewhere into the operation, a doubt about the patient’s consent crept into my mind. Was this the correct foot? The surgery was well underway. My hands are performing the amputation, guided by the surgical fellow’s voice. My mind, however, could hear nothing except the echo of uncertainty. And that echo got louder and louder inside my consciousness. A procedure of this type goes quickly. Within minutes, it was mostly completed – or completed at least past the point of return. I started feeling dizzy. My stomach, heart, and everything intertwined with them fell to, through, and below the floor. The earth seemed poised to open and swallow me. This, my mind screamed, was the wrong foot! Had I double-checked the consent form before scrubbing for the case? Why hadn’t the anesthesiologist, or the OR nurse, or the circulating nurse, or someone, ANYONE, noticed, said something, stopped the procedure, stopped us, stopped ME before it was too late? And it was too late. The bad half of the foot had been removed. We were closing the tissue that remained, cauterizing bleeding vessels, assessing for viable tissue, bringing skin over the stump, suturing, approximating skin ends, suturing, placing the sterile gauze, wrapping the foot, removing the surgical drapes, removing our own sterile gowns.

The surgery was over. I had been part of the unthinkable. I had said nothing.

“Nice job,” the surgical fellow sighed. “Get the orders done and I’ll see you on the floor.”

The anesthesiologist’s eyes followed me. Surely he knew. He said nothing. I crossed the few feet that separated us to retrieve the patient’s chart, to write orders, to check what I knew I would find. I remember the color of the small stool that, after traversing what seemed a high wire tightrope of worn floor tiling, I pretended to nonchalantly use. Breathe, I told myself. Own the mistake. Learn from this. The chart was thick; this patient had unfortunately a host of medical problems and previous hospitalizations. Still, it took no time to get to the page I wanted because I was pretty adept at finding my way around a complicated chart. My balance, though, my sense of equilibrium, well, that was something else.

The surgical consent form had my handwriting and signature. It had the patient’s signature. It also clearly had the foot indicated that needed to be amputated. A flood of confusion ran through me. We had operated on the correct foot.

Orders. Some brief conversations with nursing and the post-op team. A paragon of efficiency, I moved forward. Then I shuffled to the surgical locker room. I sat on the bench, rested my head on the front of my locker. I was not cut out for this. I was not good enough to do this. Patients deserved more. It didn’t matter that we had done the right procedure. I had not spoken as soon as I was uncertain. I was no better than those case studies we heard about and criticized.

My beeper went off. In those days, there weren’t cell phones. Nor were there digital pagers because digital technology did not exist. We had beepers, small one-way walkie-talkies that carried the voice of someone communicating from inside the hospital. It was the operator. I had an outside call.

The rotary phone in the locker room sat on the wall. A long cord connected the handset to it. I stood, grabbed the handset, dialed “O”, and leaned back against a locker, sliding to the floor. This was probably a physician transferring another patient. Or it was someone’s private doctor. Or maybe a patient’s family member.

It was my father.

I will never forget that call. Dad apologized for interrupting my day. He knew I was busy, he said. But he was just thinking about me and wanted to say hello. Hi, I said. Dad said some other things; I honestly don’t remember what they were. He probably mentioned something about Thanksgiving. Maybe he told me about my mom or siblings. All I know is that I wanted to tell him that I wasn’t fit to be a physician let alone a surgeon, that I was a failure masquerading as a model of success, that I wasn’t as tough as people thought I was, that I didn’t deserve anyone’s kindness right now. Dad had carried on in life after being paralyzed by polio. I couldn’t even keep track of whether I was operating on the correct side of a patient’s body. Even worse, I couldn’t speak up when I thought we were not.

“Sounds like you knew something to eat,” Dad said.

Food. Glucose. All of our cells knew sustenance. So do our spirits. Something awoke inside me when he told me to eat. People cared about me. The universe and its creator cared about me. This call was not random. Nor was my life, my day, and the role I had to play. Get up, something called to me. Eat something. Maybe you aren’t a perfect surgeon, or even a surgeon at all. But you can still try to be a good physician, you can still work to be a good person, and you still have people to take care of before you next sleep.

So I did.