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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