Tuesday, November 22, 2011

Favorite Case

What’s your favorite operation to do?

Whenever a non-medical person asks me this, I suspect he/she views surgery as an art form or a sport, where intense people develop a knack and passion for watercolor landscapes or the fast-break.

I want to supply a passionate response:

Gallbladder! Because, as one great physician said, it’s better to die on your feet than to live on your knees, with jaundice…

My answers routinely disappoint, especially when I’m honest. I file through operations and organs in my head searching in vain for the standout. Learning various lap colon techniques was awesome, but telling non-medical people that the colon is your favorite area? Nope. You’ve just underwhelmed them, grossed them out, or convinced them you’re creepy. Conversation over.

Instead, I try to keep the conversation alive:

I enjoy advanced laparoscopic techniques. You know, using small incisions to access the abdominal cavity and inserting a camera…

Oh, that sounds very interesting.

It is. It sure is. Very.

So, did you try the crab cakes? They’re great.

Yes, they sure are. Very.

Recently, though, I realized I processed the favorite surgery question incorrectly. For me, the fascinating part is not the operation but the exploration – the sorting, the diagnosing, the solving of crimes and mysteries.

Here is my new answer:

I live for the mysterious abdominal catastrophe. Viva la gangrene!

Indeed, I’m particularly fond of cases which begin at the scrub sink, taking bets with the resident:

What do you think, Chief? What are we going to find?

Perforated sigmoid. Totally.

Really? A six-pack says it’s not. I mean, a latte. A double grande caramel macciato says it’s ulcer.

You can’t exactly fill your operating schedule with acute mysterious catastrophes. It’s poor form to book a gunshot wound two weeks in advance. Nor can you develop a subspecialty in the look-see, unless inclined to take call at nine hospitals at once, consulting only for operative trauma and those emergent non-trauma belly cases in which the CT scan hasn’t clinched a diagnosis.

Those are the interesting ones, however. Bullet paths that make no sense. Abdominal cavities full of turbid fluid, a fibrinous slime coating every surface, and no visible perforation.

Opening a belly full of deadly mystery is indeed a fast-break. A clock is ticking, people are watching, and you must perform – now. This basket counts.

The exploratory laparotomy is also a puzzle. Often most of the picture is immediately apparent – something’s leaking, but what? You just need to root around for the few remaining pieces to have the whole picture.

Then there are the brainteasers. Obstruction, but no mass, no band, no hernia. Dang. Should I remove this twisty scarred part? Or, this whole intestine looks awful, but I can’t take it all out – it’s a necessary organ, after all. Or, everything looks normal. What explains the pain and the fluid? Can we just close up and report that everything under the hood looked just fine?

Solving these mysteries is supremely satisfying. Finding them unsolvable is even more intense. And deciding on the spot how to proceed is a commitment with consequence. It’s crazy thrilling, and I hope my new answer conveys the thrill. If not, I’ll work on my timing and delivery.

No comments:

Post a Comment