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Zen & the Art of Invasive Medical Procedures

Crack the chest. Bury your knots. Keep the blood off your hands. Corporeal. Metaphorical. Open someone up and your every action seems more significant. After ten weeks in the operating room, I have come to see simple actions—cutting, holding, sewing—as more than simple actions. I have come to wonder if the things we do everyday might carry extraordinary meaning. Consider how you peel an orange, hold a baby, tie your shoes. They are mundane actions, common gestures. But perhaps they make up who you fundamentally are.

It is an odd, very out-there statement. No, I wasn’t high when I wrote this. Let me try to explain…

During my Month of General & Trauma Surgery, the importance of simple actions first suggested themselves to me. The steadiness of your hands is a measure of your care. How well you cut or suture is how well you might heal. Surgeons are not shy about telling you when your hands are unsteady, your suturing clumsy. Mostly you quietly, motionlessly attend to the surgeon, trying to integrate your actions into theirs. You often wait in such stasis for twenty or thirty minutes, until you can perform your singular task of cutting the ends of a completed suture. As every surgeon knows, there are only two ways for a medical student to cut a knot: too short, and too long. Do it again, better. I spent more hours than I ever supposed a person might thinking about scissors. Their different weights, leverages. How to hold them. Where the blades best cut. In this motionlessness, this wordlessness, I  existed for the patient only in so far as I cut well or poorly. I existed for my surgeon only in so far as I helped or hindered. How I cut the knot determined who I was in the OR. It was humbling, painful, thought-provoking.

My mother named me after William Blake. Like my namesake, I have trouble shutting up. The OR helped me shut up. As a boy, I often listened without comprehension to mother reading her favorite lines of Blake. Twenty years later, when quietly attending to trauma surgery, open heart surgery, brain surgery, I recalled those verses and for the first time felt the importance of seeing a world in a grain of sand, heaven in a wild flower, eternity in an hour…identity in a pair of scissors.

I began to see new meaning in bodies,  my patients’ and my own. So much of the body has a parable to tell. Every human is born with a hole in the middle of their heart. It’s named the foramen ovale. Most often it closes at birth. Sometimes it doesn’t; it can be dangerous. A hole in the heart, you see the metaphor. Here’s another. There are holes in your brain, large ventricles through which light fluid moves like unconscious thought. Or… We all start as flat characters. Pancake flat. It takes months in our mothers’ bellies to grow a spine, get a heart, hold up our heads. These parables are powerful things. Cardiothoracic surgeons train for a very, very long time so they can say they fix broken hearts. Literally. Some days during open heart surgery, that particular metaphor felt like a poem; some days like a rejected country and western lyric.

True, the metaphor of the body is not equally distributed. You might, during a night of drinking, break up with a lover and wake up to find you are brokenhearted. No one in that unfortunate state would say—despite it being far closer to the truth—that they were brokenlivered[1]. Some organs carry more metaphor than others. Generally those we can see or feel—heart, lungs, eyes, stomach, skin—contain more visceral meaning than those that work in stillness and silence. Pancreas, liver, kidneys, ye unsung heroes.

Perhaps it was the sleep deprivation, but in my surgical winter I began to believe that the body is the source of all human metaphor, all poetics. The language of anatomy is the language of significance. Anatomic structures close to your surface are said to be ‘superficial;’ those near your core are ‘deep’ or ‘profound.’ In the body and the soul there is profundity and superficiality. Curl your finger with the flexor digitorum profundus muscle; pray to heaven with psalm 130, “De profundis clamavi ad te, Domine”—From the depths, I have cried out to you, Lord. I thought then that surgery was special. After the long hours, when I finally left the sterility and ceremony of the operating room, the rest of the world seemed to be painted on, to have a meaning that was only skin deep.

But on the anesthesia service, I saw it was not so. That things were far simpler.

Let’s say it’s 0630. Sunrise is changing the hospital windows from black mirrors to portraits of the morning sky. You’re up in the pre-op area, talking a sweet 72 year old lady into letting you stick a needle in her arm. On surgery, the patients were asleep. They didn’t need to be convinced or notice when your hands trembled or flinch when you punctured skin. Here, now, the moment you put steel to the back of her hand, she is exquisitely aware of you. Your existence has been focused down to a single, steel point. For the next 5 second, you are what happens at the end of that needle.

Let’s say this is the first time your attending is letting you ‘drive,’ which is to say the first time you’re pretending to know what you’re doing. A test of sorts. Saying you are nervous would be what is technically known as “a huge fucking understatement.” But, to be kind, let’s say it all goes well. A satisfying flash of blood in the needle’s chamber, a smooth advance of the catheter. You connect intravenous line and run saline into her vein. She says she feels coolness running up her arm. It’s strange for her. It’s strange for you. You just accessed her blood; you can now pour medication into her like pouring a teacup into a stream. Then comes the truly odd transformation. You wheel her back into the OR, fill her lungs with pure oxygen, induce a deep anesthetic state. Then, paralysis. She stops breathing. She has ten minutes of oxygen left.

Start. the. clock.

In your left hand, the laryngoscope, a long curved blade. Your right hand is in her mouth, scissoring open her jaw. Through your gloves you feel the sharp lines of her molars. The laryngoscope slides into her mouth; back it goes, into the back of her throat…and back…and back…far enough that it seems wrong, as if there shouldn’t be so much space in a throat. You lift…and there’s the epiglottis, the vocal cords. Like a textbook diagram. Like a toy. Eight minutes of oxygen left. The attending hands you the endotracheal tube. It feels as if it is your hand and not your hand at all that slides the tube down her throat. You slip, obstruct your own view. Pull back. Seven minutes of oxygen left. You advance the tube, but it’s trembling. Off center. You strike one of the vocal cords. Pull back again. Six minutes left. Advance again, slowly, into what you hope is her trachea.

Then the flurry of activity. Five minutes left. The attending inflates the tube’s cuff. If you intubated her stomach, he’ll have to get it out fast and mask ventilate her. You hook the tube up to the machine. Four minutes left. You squeeze the bellows. The patient’s chest rises, falls. Time becomes thick and sticky. Three minuets, thirty seconds. The clear plastic tube goes white with condensation. Wet breath? You hope. Three minuets, twenty seconds. The machine detects a long, slow CO2 wave form. It’s her exhalation.

You exhale.

And suddenly you’re in your own body again, profoundly relieved. You work the bellows and stare down at the sweet little old lady you paralyzed and for whom you are now breathing. It feels as if someone needs to do the breathing for you too. The surgeons—oblivious to your little quotidian med student drama—are draping the patient’s abdomen. You secure the endotracheal tube with tape. The attending resumes control of the case. He begins to quiz you on respiratory physiology…

And maybe that’s when you’ll agree with me how strange and yet how perfectly normal the last few minutes have been. How strange it was to exist as a needlepoint. How strange it was to be yourself and not yourself working against the oxygen clock. Maybe you’ll realize that the patient was never in any danger; that the attending could have peeled you off and mask ventilated her in twenty seconds. Maybe you’ll begin to see that when you existed for your patient as a needlepoint, when you became her lungs, you existed as a simple set of actions. In fact, this existence predated the laryngoscope, the needle. Before the steel, you were a handshake, a smile. How is this any different then when you are phone call, a signature, a body standing on an elevator?

In high school, I had a linebacker coach who was fond of belting out the mantra, “How you practice is how you play.” When I missed a tackle, he worked himself into a state of excitement that could, on account of his ruddy complexion, be described only as violaceous. “You can tell what kind of a man you are by how you tackle!” he would yell. At the time, I thought such statements were hyper-masculine bullshit, but I was probably being too dismissive. Don’t get me wrong, coach was full of hyper-masculine bullshit. So was I. But in one aspect coach was right: How one practices is how one plays. How a man tackles does say something about who he is. Recently, I went to a yoga class. The early twenty-something instructor was exhorting us to better focus on our one-legged downward facing dog poses. This despite the highly distracting qualities of modern women’s yoga pants. However, I managed to focus when the instructor invited us to see the pose as a metaphor for our lives. “How you do one thing,” she of the yoga pants said, “is how you do everything.” It is a fine mantra. Certainly it’s better than that of my linebacker coach, and yet it is also too simplified. For it is not the doing of the thing, but the awareness of the doing that reveals great meaning.

I no longer think that medical training is special in regard to the importance of actions, merely that the danger to others and the metaphor of the body demand a state of attentiveness, of awareness that accentuates the meaning of those actions.

It is a shame that cultivating attentiveness is so difficult, requires so much effort. It is a state that is more easily found by the journeyman than the master. An attending surgeon sews almost without thought, so finely has the action been trained into the mind. The attending anesthesiologist intubates without agitation or dissociation. To paraphrase Gawande, conscious training becomes unconscious skill. Masters operate unconsciously, freeing their thoughts to analyze nuances, construct contingency plans, or in the case of orthopedic surgeons, sing along to the 80s glam bands. (Why, I wonder, does every orthopod in my hospital seem to have a thing for Bon Jovi?) Mastership is a wonderful thing. We wouldn’t have open heart surgery or the Mona Lisa or the Statue of Liberty without it; however, mastership makes it harder to find a state of awareness, of attentive grace that allows the meaning of our actions to become apparent. In a way, our daily lives are mundane because we have all become masters at eating sandwiches, riding an escalator, sneezing.

Perhaps, with a little effort, we might try to see through our mastery of common actions, approach the next handshake as if were our first, sip our next lemonade as if we never had done so before. Such a state would not be sustainable throughout a workday, or maybe even an hour. But at times, perhaps we can play the way we practice, do everything as we do one thing. Since leaving the OR, I have had a few moments of attentive grace in the everyday world. During those moments, it seems obvious to me that the way you comfort a friend is your philosophy; the way you fold your shirts, your political beliefs; the way you walk across a sunlit room, your religion.



[1] Unless they were an Elizabethan. Four hundred years ago, the anglos believed the liver and not the heart was the seat of passion. A coward was thought to have a bloodless, and therefore pale, liver; whence we get the archaic insult ‘lily livered.’  There are other, alternative systems of bodily metaphor. Famously, the ancient Egyptians thought the brain of no importance and so discarded it during mummification. What bitter irony it must have been then for the pharos then to arrive in the afterlife with their wives to discover their preserved bodies lacked brains. However, I should admit that some men might find nothing ironic at all about entering an afterlife without a brain but with eternal parts ranging from a heart to a penis.  Some, in fact, might even think it approximated paradise.

Comments

13 Responses to “Zen & the Art of Invasive Medical Procedures”

  • Great post, Blake. The perspective-broadening quality of it is just invaluable and was right up my alley. Thanks for writing it.

  • A writing professor once reminded my class repeatedly that good writing should make the familiar seem strange and new–I think that’s the attentiveness of which you speak. A good piece of art should make us see that which we have mastered and come to find as commonplace in a new light, so that we give it our full attention again.

    I kind of wish my career involved a little more metaphor, though. A little jealous!

    • Maybe you should practice starting an IV line on any kid that gets below a C+? Okay, maybe not.

      I do like what your professor. One of my favorite writers likes to say that to describe something well is to see it completely for the first time.

  • mordantkitten

    8:39 am Mar-27-2012

    Reply

    Any surgeon who puts that much thought and art into their work can carve me up any time I need it. Are you considering a surgical residency?

    Given that Bon Jovi did “Shot Through The Heart”, I suppose we should be glad it’s the ortho surgeons and not the cardio who listen to them. I’ve read that music, just like conversation, can sneak into the patient’s brain during the op. Eek. Next time I have surgery, I’m requesting a soundtrack. Can we do that?

    • Though I loved my time as a cutter, and found surgery fascinating, I have to rank a surgical career low on the list of possibilities; it’s not conducive to writing novels.

      As for requesting a soundtrack, it would depend on the surgeon. I saw some ask the patient if they had a favorite song they wanted played. I worked with other surgeons that forbid any music. I always liked it when we played music requested by the patient. It made it seem as if their presence as a personality (rather than a body under drapes) was more evident.

  • Wow. Just discovered your blog through a picture on ‘Writers’ on Facebook. I am so happy to have discovered your blog. Pulled me right in. Loved it. Thank you.

  • I found you by way of a recent Dr. Verghese article and then through the Stanford 25. As a MD/ PhD student, one line in particular stands out in relation to our training: “For it is not the doing of the thing, but the awareness of the doing that reveals great meaning.” Too often we as students focus too hard on the actual act but not the significance behind it or the hidden learning associated with it. We are unable to see the forest in the trees. Your medical posts and the associated feeling are very eloquently stated; I only wish I could do the same!

    • Hi Robert, thank you kindly for stopping by and for the kind words. I agree completely about seeing the forest, and I do hope it becomes easier for us as we move forward with training. I’m about to sit for Step 2 and after that it’ll be a wrap on med school. Hopefully then I’ll have time for a few more posts. Meantime I hope you’re well

  • Your description of the anesthesiologist’s race against time had my heart pounding! In addition to the blog above, I have read through much of your website, and you are a really imaginative dude! I am a dyslexia reading specialist and I saw your bio on an ad for NCBIDA’s upcoming workshop on February 1st, which I will be attending. I am looking forward to purchasing copies of your books for my students’ – and my own – enjoyment!

    • Hi Karen, Thank you for the kind words! I’m glad that piece worked out for you. Given that I’m a little more than half way through intern year (the first year of being a doctor), it seems like lifetime ago that I wrote that. I’m just now geering up for my talk on Feb 1st, so I hope you like it and hope I get a chance to say hi in person there 😉

  • This is so beautifully written. As a writer and a paramedic who just attended a class on RSI two days ago, I’m amazed at how cleanly and poetically you describe the act (or art) of intubating a paralyzed person. That is no simple feat! The writing of it, I mean. And as a person who practices yoga and mindfulness (although not football) I loved the way you integrated medicine with mindfulness with the art of living. Well done!

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