An unexpected question in a pub

Earlier this week, I was in Washington to attend my first ever NIH study section as an actual reviewer. It was definitely an illuminating experience, and overall I left with, believe it or not, more faith in the system the NIH uses to determine how grant money is doled out. Maybe I’ll become more cynical after I’ve attended a few, but this session was full of very fair but tough-minded reviewers who really wanted to score everything high but couldn’t. Perhaps I’ll write in more detail about it after I’ve had a chance to absorb the experience; given the confidentiality of the meeting (we had to turn in all the grants and our reviews at the end, including CDs), I’m not sure how much I could actually discuss, and a post of vague generalities probably wouldn’t satisfy you, my reader, that much. Certainly, it wouldn’t deliver your daily recommended quota of Respectful Insolence™.

So how about an anecdote about something that happened the evening after the study section meeting ended instead?

I had driven down to D.C. this time and rather regretted it. The last couple of days, the entire mid-Atlantic coast has been deluged with enormous quantities of rain, and it began in earnest Sunday evening while I was on my way. It took me over an hour to get through the 10 mile stretch of the Delaware Turnpike, and, as I neared D.C., intermittent violent downpours turned visibility to near zero and seriously tempted me to pull over and wait for Nature’s fury to pass. Eventually, I made it to the hotel, but the trip took nearly two hours longer than it normally does.

I had booked the hotel for the night after the study section, in case it ran so late and I was so tired that I didn’t feel like driving home. Consequently, I found myself in D.C. alone with not much to do; so I hopped on the Metro and headed over to Dupont Circle. When I got on the Metro, it wasn’t raining; when I got off and ascended that long escalator leading up from the very maw of the earth to the light of day, I was met with buckets of water falling on my head, a torrent that my pitiful umbrella seemed ill-equipped to cope with. So much for my plan of wandering around. Fortunately, I had a backup, which was to head on over to the Brickskeller, which happens to have what is advertised to be the largest selection of beers in North America, if not the world–over a thousand. Getting there involved negotiating the deluge, but I managed to make it there, shaking my umbrella and clothes like a wet dog before plunging into the building, up a flight of stairs, and to the bar.

The Brickskeller is my kind of place. Besides the huge assortment of beers to sample, it’s an old, musty space, with wood finish everywhere, lots of beer paraphenalial lining the walls, a dartboard, and, of course, sports on the TVs. I sidled up to the bar. One disadvantage of such a huge selection of beer is that it made it very difficult to decide on one; ultimately I took the bartender’s advice and tried a Southhampton wheat beer, which was quite good, ordered a burger, and settled down to watch a baseball game. Sitting next to me was a guy who looked to be a few years younger than I and who also looked to have gotten a considerable head start on me as far as sampling the wares of this establishment. He pulled out a cigarette, turned to me, and asked, “Do you mind?”

Actually, I did (I hate having to breathe someone else’s carcinogens), but, this being a bar and all and not in a state or city that’s banned smoking in public buildings, I didn’t see any point in objecting. “Go ahead, I said, and returned to watching the game and waiting for my food. Unfortunately, the beer had made him a bit garrulous, and he wanted to have a conversation. So, we made small talk; I learned that he worked for an electronics company and had to do a lot of traveling for his business.

“So what do you do?” he asked.

I hate this part. Think of it this way. If you happened to find yourself next to a guy in a bar killing time waiting for the rain to stop, and, when you asked him what he did, he told you he was a surgeon who also did research, how would you react? You’d probably want to know more and would ask a whole bunch of questions. You might not even believe him entirely, depending upon the bar the conversation took place in. Besides, what I do takes a fair amount of effort to explain, even with simplification; so usually I end up retreating to just saying that I’m a surgeon.

Which is exactly what I did in this case.

And then it hit me, the question. It was somewhat tentative, as if he knew it was perhaps asking too much, but he asked it of me nonetheless, “So, what’s it like to cut into someone?”

Come on, be honest, you’ve wondered that, too, haven’t you?

This is where what I said and what I should have said diverged. So caught off balance by the question, what I said was a mumbling description of how I have to be very careful because I can mess someone up really bad if I’m not careful. Very nice. Very eloquent. Geez, I couldn’t have confirmed the stereotype of the inarticulate surgeon any better if I had tried.

Later that night, after I had made it back to the hotel, even wetter than I had been entering the bar, I realized the answer that I should have given. I don’t know if it’s really all that better, but I thought it was at the time.

My mind wandered back to the first major surgery I had ever seen as a medical student. I don’t remember the details anymore other than that it was a bypass of a renal artery stenosis (narrowing) to fix renovascular hypertension. I recall how I marveled at the surgeon’s ability to carefully move all the glistening bowel out of the way and expose the kidney and aorta, to clamp the aorta, and sew a bypass graft from the aorta to the renal artery beyond the obstruction. I remembered another day, early in my vascular surgery rotation. A scheduled repair for an abdominal aortic aneurysm (AAA) had to be cancelled when the patient had a cardiac arrest on induction of anaesthesia, requiring him to be wisked away to the ICU, leaving the O.R. table unnoccupied–until a patient with a ruputured AAA landed in the E.R. and had to be brought to that same O.R. table in dire straits, while the other student and I helped form the “bucket brigade” checking units of blood before the anaesthesiologist poured them into the patient as fast as pressure bags would force them in, with blood everywhere on the floor, pouring out faster than we could pour it in and the cell saver could give it back. That was the first time I ever noticed–really noticed–that human blood has a distinct odor, as that odor filled my nostrils.

The patient died, despite the team’s best efforts.

Nowadays, routine surgery, such as breast biopsies or other elective surgery, it doesn’t even raise my pulse anymore. But I never forget that, society has granted me and relatively few others the privilege to cut into living human bodies legally in order to try to cure them of disease. I like to think that I’ve earned that right through my skill, but it could just as easily have gone the other way. Even now, there is a certain awe to even the most minor surgery, awe that I can slice hunks of tissue secure in the knowledge that the body, using an intricate mechanism of inflammation and healing that has evolved over millions upon millions of years, can heal the would left behind. There is fear, too, coming from the realization that the patient is a human being just like me and that, should my skill fail or should misfortune lead to a mistake, that I can mess that patient up in a big way for the rest of her life. The fear is, of course, proportional to the difficulty and invasiveness of the particular surgery. I’m way beyond fear when it comes to minor surgerys, such as a breast biopsy, but larger surgeries certainly bring it out, particularly since I don’t do them as often as I used to. The fear must be suppressed in order to what needs to be done, but it’s there in the background nonetheless, even in the most experienced, wiliest surgeons. We surgeons speak admiringly of other surgeons whom nothing that happens during an operation seems to rattle as “fearless,” but that’s not quite the case, I think. In reality, it’s a supreme confidence in one’s ability that allows the surgeon to overcome the fear of failure, the fear of hurting or even killing the patient, along with a certain necessary intellectual detachment.

And, finally, there is amazement: Amazement at the intricate structures; amazement at the not-so-intricate structures that my training tells me are actually quite intricate at the cellular level; amazement that it’s possible to alter those structures and actually help the patient (it’s not for nothing that we sometimes joke about “rearranging people’s anatomy”; amazement that blood will clot, that the body will fill in defects, that you can sew two blood vessels together and get a functional blood vessel or that you can sew two loops of bowel together and they will heal into a continuous tube without leaks; amazement that a patient whose abdomen you rooted around in for hours and whose anatomy your rearranged is often ready to go home in a matter of days, problem resolved. But mos of all, there is amazement that I can actually do some of these things..

Of course, if I waxed that lyrical, it’s hard to know if my erstwhile bar companion would have been fascinated or thought that he had given a huge bore a chance to start pontificating after downed a pint. Maybe he would have been wanting to avoid my answer as much as I had wanted to avoid the question.

By Orac

Orac is the nom de blog of a humble surgeon/scientist who has an ego just big enough to delude himself that someone, somewhere might actually give a rodent's posterior about his copious verbal meanderings, but just barely small enough to admit to himself that few probably will. That surgeon is otherwise known as David Gorski.

That this particular surgeon has chosen his nom de blog based on a rather cranky and arrogant computer shaped like a clear box of blinking lights that he originally encountered when he became a fan of a 35 year old British SF television show whose special effects were renowned for their BBC/Doctor Who-style low budget look, but whose stories nonetheless resulted in some of the best, most innovative science fiction ever televised, should tell you nearly all that you need to know about Orac. (That, and the length of the preceding sentence.)

DISCLAIMER:: The various written meanderings here are the opinions of Orac and Orac alone, written on his own time. They should never be construed as representing the opinions of any other person or entity, especially Orac's cancer center, department of surgery, medical school, or university. Also note that Orac is nonpartisan; he is more than willing to criticize the statements of anyone, regardless of of political leanings, if that anyone advocates pseudoscience or quackery. Finally, medical commentary is not to be construed in any way as medical advice.

To contact Orac: [email protected]

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