A tiny baby on a big table in a huge OR

The potential to do dramatic good, as is the case with surgery, means that sitting and staring back at you at the other end of the see-saw is a grinning dysmorphic ogre. He keeps his eyes locked on yours, staring with the smug certainty that you can’t toss him off, up when you’re down; down when you’re up. The ugly little sonovabitch never goes away. It’s an issue for every healthcare provider. Were it front and center at all times, it’d be paralyzing. But if it’s completely out of mind, you’d become dangerous, or careless at the least.

So there’s craziness: much as I find doing surgery exhilarating and fun, and much as I’m amazed at and grateful for the willingness of people to turn their bodies — with their most intimate secrets — over to me, in the entryway to the back of my mind resides the awareness that it’s a dangerous thing I do. Thin ice. There’s a lizard under every rock. Sometimes the realization comes upon me like a bucket of ice-water. (I should acknowledge that — maybe unique in the “dangerous” professions — in my case the danger is the patients’. A mentor of mine said, “The patient takes all the risk, Dockie.” I don’t minimize that. But to harm another is, in many ways, worse than harming yourself.)

Imagine being the parents of a perfect baby. All the fears of pregnancy and expectations of birth have resulted in a beautiful boy, thriving. Looks like his dad. Other than being tired all the time, you’re ecstatic with the love you have for this little thing. He coos, he looks lovingly back at you as you feed him. And now he’s six weeks old, and you’re being told he needs an operation.

Having fed quite normally for the first month or more, the baby is now vomitting, more and more forcefully, until it seems he’s keeping nothing down, and isn’t gaining weight. Hypertrophic pyloric stenosis, the surgeon says, speaking Greek, or Martian. Like a raw doughnut tossed into the fryer, the circular muscle at the bottom of the stomach has grown, and it’s preventing food from leaving the stomach. The treatment is surgery.

As operations go, it’s quite simple. Many years ago, part of the stomach was removed: in starving kids, that’s a big deal, and lots of them didn’t do well. The modern operation is quick and comparatively trauma-free, and works great. You make a small incision on the baby’s belly, find the enlarged muscle, and slice into it, splitting the muscle fibers (it looks strange: instead of the healthy pink, the muscle looks like the meat of a white peach) and spreading them apart.

Imagine a tight ring over a glove on a finger. You want to cut the ring, but not the glove. You want to see the glove fabric bulge up into the cut you made, indicating it’s free. But if you cut the fabric, you’ve done a bad thing. The glove is the inner lining of the stomach: the mucosa. A hole in it means leakage of stomach contents. Making it tricky, it sort of folds over on itself exactly at the bottom end of the muscle. You need to cut the entire muscle or the operation won’t be effective; but if you go too far, you make a hole. Doing so isn’t the worst thing in the world: if you recognize it, you sew it up and there’s no problem. The danger is puncturing the mucosa and not noticing. That can be deadly.

So you explain all this to the parents. You tell them about the possible problem, but say that prevention is what we’re all about in doing the operation. You say that the kid might still vomit a bit for a few hours, but in all likelihood, he’ll be home in a day or two, doing fine. Like magic. They agree, of course.

There’s something completely wrong about a tiny baby on a big table in a huge OR. I could cover the entire person with my two hands. All the machinery, the tools, the drapes, the surrounding team seem terrifyingly outsized. It’s like a joke. We’re playing dolls. Except it’s real and the stakes are high. It’s one of those times when I ignore the reality and just focus on the job at hand. Tiny hole, tiny instruments, fine little sutures at the end. It goes fine.

“Shit,” I say, as the phone rings at two a.m. It’s my usual response, whatever the call. This time the nurse tells me the baby has a fever of 103 and his abdomen is rigid. “I’ll be right there,” I tell her, the words finding great resistance, barely squeezing out through my suddenly constricted throat.

It’s easy to describe how I felt, because I feel that way again whenever I think about it. Had my wife awakened, she’d have seen me appear ghost-white, I’m certain. My stomach was hollow; my hands were ice. I could barely tie my shoes; my hands were shaking, and not following commands. It felt as if a cold hand were gripping my neck; I could hardly swallow. I splashed water on my face, made it to my car, raced to the hospital. As I drove, hands so tighly on the wheel that they were getting numb, I was thinking I’d do whatever was in my power to save the kid, do whatever it takes. Never leave him until it was over. And then I’d never, never, ever, ever do a pyloromyotomy again. And if he did poorly, I’d never operate again. This was a baby. Someone’s precious baby.

As I headed to the pediatric floor and entered the baby’s room, saw the nurse standing by, I felt as if a million eyes were on me, accusing and hateful. (They weren’t. But that’s how I felt.) And there he was. Fussy face flushed with fever, but moving around like a baby, looking not so bad. His belly was soft as, well, a baby’s bottom. An xray looked fine (before surgery, to make the diagnosis, he’d been made to swallow some dye. It still showed up, some in his stomach, some happily in his intestine, and none at all outside the proper confines.)

Who knows what it was? The kid did fine and went home, as promised, in a day or so.

I drove home nearly limp, still shaking, barely able to control the car, wrung out like a wet sock. I lay on the bed exhausted; relieved, but absolutely spent. An hour or so later, I dragged myself to work. And next time a pediatrician called for a consult for a kid with pyloric stenosis, I took a deep breath, considered it carefully, and said, “I’ll be right there.”

Sid Schwab is a retired surgeon and author of Cutting Remarks: Insights and Recollections of a Surgeon.

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  • Ron Smith

    Sid, thanks for the post.

    You don’t have to be surgeon even for that experience. I mean as a Pediatrician who did level 3 neonatal care in a relatively remote home state town for 6 1/2 years…I had many gut wrenches like that and worse. The smallest baby I cared for was a pound and thirteen ounces. He went home fine, but it took three months and he was one of the first to get Exosurf, as we were in the last of the clinical use trials before it was finally released.

    There have been one long string of “I’ll never see that again” cases since I started 30 years ago.

    Kids are harder than most people think too. My daughter just had her fourth child and the baby is about three weeks old. Andrea is not a new mother. The baby was fussy the other night, and after listening to Andrea’s detailed, I told her that I just needed to look at the baby when I got home from work.

    I got my little granddaughter in my arms and I looked. Yes, that’s all I had to do was a good, long look. I didn’t see or hear anything, but just holding her in my hands gave me a sense that she was OK. I handed her back to Andrea and she said, “Is that all?” I said yes. I just needed to put my hands on her to get a sense of her well-being. Everything turned out fine.

    Where’s that in a textbook? How do teach that sixth sense in residency?

    Much as I embrace and utilize every digital technology for the good of my patients, this is something that I simply have not been able teach except when a resident or nurse practitioner is right by my side. Sometimes, I just seem to know when somethings wrong. There is not any ‘evidence’ but something inside me says ‘better be a little more careful with this one.’

    Case in point. I had a young girl about 8 or so who was a well established patient of mine. Mom brought in her because she was complaining of headaches. Every day almost. And only in the mornings it seemed. For about the last couple of months at most.

    It was a hard thing to convince the Kaiser doc to approve the MRI. But I saved them a lawsuit and that girls life when we found the brain tumor.

    And I’ll probably never see that again either! It wasn’t on my bucket list, but toss it in anyway!

    Warmest regards,

    Ron Smith, MD
    www (adot) ronsmithmd (adot) com

    • Sid Schwab

      Well said, Ron. I wrote an article about the disappearing art of physical diagnosis, too. A central point was that no matter how much info I had about the patient before seeing her or him, xrays, lab data, etc, I never felt I knew much until I actually walked into the room and looked. And sensed, and touched.

  • http://ClinicalPosters.com/ ClinicalPosters

    Thanks for sharing the emotion behind the job that others likely quite often take for granted.

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