BlakeCharlton.com

Making a Hepatoportoenterostomy Look Like Child’s Play: Dr. Sanjeev Dutta, Pediatric Surgery

If you’ve talked to me in the past few weeks, I probably bubbled incoherently about an amazing day shadowing a pediatric surgeon. It’s still early to know what I will go into, but so far feels it feels like a life-changing experience. The following is a reprint from an article I wrote for a “Day in the Life” feature in H&P–Stanford Med’s student publication. Hopefully it provides a more articulate description of what that day was like.

It’s an autumn wine-and-cheese surgery social; most scalpel-wielders are styling the oxford wool and sensible haircut look. That’s why Dr. Sanjeev Dutta’s black leather jacket and spiky hair is so easy to spot. His predilection for Family Guy jokes and indie rock in the OR have won him a reputation as the “cool and approachable” attending in pediatric surgery. After needling a second year for an introduction, I discover Dutta’s demeanor is quirky and relaxed–a fact that belies his forty published journal articles, eleven book chapters, and hand in endeavors ranging from the Stanford’s Goodman Simulation Center to the surgical device design at SRI International.

With a little tap-dancing about my novels for young (at least at heart) people and a technical writer for the pediatrics department, I convinced Dutta to let me shadow him. And so a few days later, I–a month into med school and barely able to distinguish mesentery from smooth muscle–wake to an alarm crowing out 5am so I can bike to the hospital and round with the peds surg team before the big DoD: Day of Dutta.

7:24am — The team catches up with Dutta in a small pre-op holding room. He’s standing before two anxious parents. Their five-year-old son, AS, is wailing in the mother’s arms. The boy has messy brown hair, wide dark eyes, and Hirschsprung Disease–a developmental condition that has left the last few inches of his descending colon without the ganglia necessary for rectal relaxation. Dr. Dutta had hoped to correct AS’s condition with a “pull through” surgery, which would remove the aganglionic bowel and pull the innervated colon down to the rectum. But AS’s body is running a fever and his nose is running something much worse than that. When Dutta explains that the flu makes surgery too dangerous, the mother is visibly relieved. The father, however, launches a bevy a questions about rescheduling. He’s frightened and more than a little angry. The couple had to wake up at three in the morning to drive out from the Central Valley–an expensive endeavor, given the price of gas and a missed workday. Nodding sympathetically, Dutta acknowledges the aggravating situation. They begin to discuss what to look for in their son before bringing him in again. Meanwhile the team spills back into the general holding area. The pull-through was supposed to fill the entire morning. The unexpected opening in the schedule has to be filled.

7:45am — In the darkness of the peds reading room, the team huddles around three luminescent computer screens. The resident is reviewing patient radiographs. Dutta interrupts with a few pointed questions but remains focused on the search. The situation’s a sticky wicket: the afternoon’s reserved for a Kasai procedure–an elaborate operation that could run late if its start is delayed. As a result, our hunt is for a patient who needs a discreet procedure that will not require too much preparation.

8:03am — After identifying a fifteen-month-old in need of a central line, the team hikes up to Ward Three East only to discover that the patient’s INR–a measure of extrinsic blood coagulation–has risen to nearly double the normal value. After consulting the nurses, Dutta decides surgery is too risky. With the hunt back on, the team defaults to rounding.

8:16am — On Ward Two West sunlight is at last pouring through the windows to illuminate the rooms. The team has discovered an unusual but promising candidate. At only nine months old, ML has endured more trouble than most do in a lifetime. Born with a pelvic duplication anomaly, ML possessed two bladders, two uteri, two urethras, and two vaginas. Counter intuitively, none of this doubling is causing her trouble; all the plumbing seems connected and functional. But the partial duplication of the bones of her pelvis was a different story. The orthopedic surgery to correct the bones has disturbed her bowel into producing obstructing adhesions that need to be removed. After examining ML’s chart, Dutta consults her nurse and pediatric cardiology. When all the responses come back positive, he gives the nod and we are off.

8:55am — As OR 21 bustles with the rituals of preparation, Dutta quizzes the team about the procedure and hands me a few CDs with instructions for “something loud to start off.” That loud something turns out to be The White Stripes played at top volume on the OR’s computer. A few minutes later, the patient is ready and the stage is set. I’m amazed by the tiny surgical field. To me, ML’s miniature and delicate anatomy seems to require cuts so exact they’d make a ninja sweat. But Dutta and his team make the opening incision with precision and a calm confidence.

10:20am — With ML’s tiny bowel now completely exposed, both Dutta and his resident scrutinize its every centimeter for adhesions. Meanwhile The White Stripes album ends, and Dutta asks for an obscure indie group named The Knife. If you could mash Bjork’s vocals with Moby’s electronica background and then pushed them both down a long flight of stairs with a baby grand piano, it’d sound pretty close to the resulting experimentation of beat, chorus, and cacophony that comes blasting out of the computer. It’s not bad, just very very strange. Before long, the team is joshing Dutta about his strange musical taste. Smiling, he returns fire and gives as good as he gets.

10:34am — The ribaldry goes quite as Dutta discovers a dark knot of strangulated bowel. On direction, I turn down the music so the team can focus on resecting the bit of small intestine.

10:45am — With the troublesome section of gut removed and the resulting ends anastomosed, the atmosphere lightens. As Dutta directs the closure, talk within the team ranges from Star Wars to the golden age of Hip Hop.

11:27am — With ML closed and her condition looking optimal, the team readies for lunch. Most everyone is talking about the upcoming Kasai Procedure, which involves the removal of a defective gallbladder and common bile duct, with direct connection of the small intestine to the liver. I’m disappointed that I won’t be able to see the surgery; I have an anatomy “walkabout” exam on the upper limb. More troublesome (in a meta-journalism kinda way) I don’t know how I’m going to write the “Day in the Life” article I’ve promised to H&P. Dutta laughs when I tell him this. “Don’t worry: I’ll tell you how it will go,” he says. “We’ll start the Kasai around three. It’ll run until about six. I’ll get to the gym in time to meet my wife on the treadmill. We’ll dash home to enjoy a dinner and a glass of wine. I’ll fall asleep the moment my head hits the pillow, and get up tomorrow to do it all over again.” His grin suggests he wouldn’t have it any other way.