Writer, M.D.

by Leah Kaminsky

  But, of course, mine were not experienced hands. And the disasters I knew about weighed on my mind: the woman who had died within minutes from massive bleeding when a resident lacerated her vena cava; the man whose chest had to be opened because a resident lost hold of a wire inside the line, which then floated down to the patient’s heart; the man who had a cardiac arrest when the procedure put him into ventricular fibrillation. I said nothing of such things, naturally, when I asked the patient’s permission to do his line. He said, “OK.”

  I had seen S. do two central lines; one was the day before, and I’d attended to every step. I watched how she set out her instruments and laid her patient down and put a rolled towel between his shoulder blades to make his chest arch out. I watched how she swabbed his chest with antiseptic, injected lidocaine, which is a local anesthetic, and then, in full sterile garb, punctured his chest near his clavicle with a fat three-inch needle on a syringe. The patient hadn’t even flinched. She told me how to avoid hitting the lung (“Go in at a steep angle,” she’d said. “Stay right under the clavicle”), and how to find the subclavian vein, a branch to the vena cava lying atop the lung near its apex (“Go in at a steep angle. Stay right under the clavicle”). She pushed the needle in almost all the way. She drew back on the syringe. And she was in. You knew because the syringe filled with maroon blood. (“If it’s bright red, you’ve hit an artery,” she said. “That’s not good.”) Once you have the tip of this needle poking in the vein, you somehow have to widen the hole in the vein wall, fit the catheter in, and snake it in the right direction—down to the heart, rather than up to the brain—all without tearing through vessels, lung, or anything else.

  To do this, S. explained, you start by getting a guide wire in place. She pulled the syringe off, leaving the needle in. Blood flowed out. She picked up a two-foot-long twenty-gauge wire that looked like the steel D string of an electric guitar, and passed nearly its full length through the needle’s bore, into the vein, and onward toward the vena cava. “Never force it in,” she warned, “and never, ever let go of it.” A string of rapid heartbeats fired off on the cardiac monitor, and she quickly pulled the wire back an inch. It had poked into the heart, causing momentary fibrillation. “Guess we’re in the right place,” she said to me quietly. Then to the patient: “You’re doing great. Only a few minutes now.” She pulled the needle out over the wire and replaced it with a bullet of thick, stiff plastic, which she pushed in tight to widen the vein opening. She then removed this dilator and threaded the central line—a spaghetti-thick, flexible yellow plastic tube—over the wire until it was all the way in. Now she could remove the wire. She flushed the line with a heparin solution and sutured it to the patient’s chest. And that was it.

  Today, it was my turn to try. First, I had to gather supplies—a central-line kit, gloves, gown, cap, mask, lidocaine—which took me forever. When I finally had the stuff together, I stopped for a minute outside the patient’s door, trying to recall the steps. They remained frustratingly hazy. But I couldn’t put it off any longer. I had a page-long list of other things to get done: Mrs. A needed to be discharged; Mr. B needed an abdominal ultrasound arranged; Mrs. C needed her skin staples removed. And every fifteen minutes or so I was getting paged with more tasks: Mr. X was nauseated and needed to be seen; Miss Y’s family was here and needed “someone” to talk to them; Mr. Z needed a laxative. I took a deep breath, put on my best don’t-worry-I-know-what-I’m-doing look, and went in.

  I placed the supplies on a bedside table, untied the patient’s gown, and laid him down flat on the mattress, with his chest bare and his arms at his sides. I flipped on a fluorescent overhead light and raised his bed to my height. I paged S. I put on my gown and gloves and, on a sterile tray, laid out the central line, the guide wire, and other materials from the kit. I drew up five cc’s of lidocaine in a syringe, soaked two sponge sticks in the yellow-brown Betadine, and opened up the suture packaging.

  S. arrived. “What’s his platelet count?”

  My stomach knotted. I hadn’t checked. That was bad: too low and he could have a serious bleed from the procedure. She went to check a computer. The count was acceptable.

  Chastened, I started swabbing his chest with the sponge sticks. “Got the shoulder roll underneath him?” S. asked. Well, no, I had forgotten that, too. The patient gave me a look. S., saying nothing, got a towel, rolled it up, and slipped it under his back for me. I finished applying the antiseptic and then draped him so that only his right upper chest was exposed. He squirmed a bit beneath the drapes. S. now inspected my tray. I girded myself.

  “Where’s the extra syringe for flushing the line when it’s in?” Damn. She went out and got it.

  I felt for my landmarks. Here? I asked with my eyes, not wanting to undermine the patient’s confidence any further. She nodded. I numbed the spot with lidocaine. (“You’ll feel a stick and a burn now, sir.”) Next, I took the three-inch needle in hand and poked it through the skin. I advanced it slowly and uncertainly, a few millimeters at a time. This is a big goddam needle, I kept thinking. I couldn’t believe I was sticking it into someone’s chest. I concentrated on maintaining a steep angle of entry, but kept spearing his clavicle instead of slipping beneath it.

  “Ow!” he shouted.

  “Sorry,” I said. S. signaled with a kind of surfing hand gesture to go underneath the clavicle. This time, it went in. I drew back on the syringe. Nothing. She pointed deeper. I went in deeper. Nothing. I withdrew the needle, flushed out some bits of tissue clogging it, and tried again.

  “Ow!”

  Too steep again. I found my way underneath the clavicle once more. I drew the syringe back. Still nothing. He’s too obese, I thought. S. slipped on gloves and a gown. “How about I have a look?” she said. I handed her the needle and stepped aside. She plunged the needle in, drew back on the syringe, and, just like that, she was in. “We’ll be done shortly,” she told the patient.

  She let me continue with the next steps, which I bumbled through. I didn’t realize how long and floppy the guide wire was until I pulled the coil out of its plastic sleeve, and, putting one end of it into the patient, I very nearly contaminated the other. I forgot about the dilating step until she reminded me. Then, when I put in the dilator, I didn’t push quite hard enough, and it was really S. who pushed it all the way in. Finally, we got the line in, flushed it, and sutured it in place.

  Outside the room, S. said that I could be less tentative the next time, but that I shouldn’t worry too much about how things had gone. “You’ll get it,” she said. “It just takes practice.” I wasn’t so sure. The procedure remained wholly mysterious to me. And I could not get over the idea of jabbing a needle into someone’s chest so deeply and so blindly. I awaited the X-ray afterward with trepidation. But it came back fine: I had not injured the lung and the line was in the right place.

  Not everyone appreciates the attractions of surgery. When you are a medical student in the operating room for the first time, and you see the surgeon press the scalpel to someone’s body and open it like a piece of fruit, you either shudder in horror or gape in awe. I gaped. It was not just the blood and guts that enthralled me. It was also the idea that a person, a mere mortal, would have the confidence to wield that scalpel in the first place.

  There is a saying about surgeons: “Sometimes wrong; never in doubt.” This is meant as a reproof, but to me it seemed their strength. Every day, surgeons are faced with uncertainties. Information is inadequate; the science is ambiguous; one’s knowledge and abilities are never perfect. Even with the simplest operation, it cannot be taken for granted that a patient will come through better off—or even alive. Standing at the operating table, I wondered how the surgeon knew that all the steps would go as planned, that bleeding would be controlled and infection would not set in and organs would not be injured. He didn’t, of course. But he cut anyway.

  Later, while still a student, I was allowed to make an incision myself. The surgeon drew a six-inch dotted l
ine with a marking pen across an anesthetized patient’s abdomen and then, to my surprise, had the nurse hand me the knife. It was still warm from the autoclave. The surgeon had me stretch the skin taut with the thumb and forefinger of my free hand. He told me to make one smooth slice down to the fat. I put the belly of the blade to the skin and cut. The experience was odd and addictive, mixing exhilaration from the calculated violence of the act, anxiety about getting it right, and a righteous faith that it was somehow for the person’s good. There was also the slightly nauseating feeling of finding that it took more force than I’d realized. (Skin is thick and springy, and on my first pass I did not go nearly deep enough; I had to cut twice to get through.) The moment made me want to be a surgeon—not an amateur handed the knife for a brief moment but someone with the confidence and ability to proceed as if it were routine.

  A resident begins, however, with none of this air of mastery—only an overpowering instinct against doing anything like pressing a knife against flesh or jabbing a needle into someone’s chest. On my first day as a surgical resident, I was assigned to the emergency room. Among my first patients was a skinny, dark-haired woman in her late twenties who hobbled in, teeth gritted, with a two-foot-long wooden chair leg somehow nailed to the bottom of her foot. She explained that a kitchen chair had collapsed under her and, as she leaped up to keep from falling, her bare foot had stomped down on a three-inch screw sticking out of one of the chair legs. I tried very hard to look like someone who had not got his medical diploma just the week before. Instead, I was determined to be nonchalant, the kind of guy who had seen this sort of thing a hundred times before. I inspected her foot, and could see that the screw was embedded in the bone at the base of her big toe. There was no bleeding and, as far as I could feel, no fracture.

  “Wow, that must hurt,” I blurted out, idiotically.

  The obvious thing to do was give her a tetanus shot and pull out the screw. I ordered the tetanus shot, but I began to have doubts about pulling out the screw. Suppose she bled? Or suppose I fractured her foot? Or something worse? I excused myself and tracked down Dr. W., the senior surgeon on duty. I found him tending to a car-crash victim. The patient was a mess, and the floor was covered with blood. People were shouting. It was not a good time to ask questions.

  I ordered an X-ray. I figured it would buy time and let me check my amateur impression that she didn’t have a fracture. Sure enough, getting the X-ray took about an hour, and it showed no fracture—just a common screw embedded, the radiologist said, “in the head of the first metatarsal.” I showed the patient the X-ray. “You see, the screw’s embedded in the head of the first metatarsal,” I said. And the plan? she wanted to know. Ah, yes, the plan.

  I went to find Dr. W. He was still busy with the crash victim, but I was able to interrupt to show him the X-ray. He chuckled at the sight of it and asked me what I wanted to do. “Pull the screw out?” I ventured. “Yes,” he said, by which he meant “Duh.” He made sure I’d given the patient a tetanus shot and then shooed me away.

  Back in the examining room, I told her that I would pull the screw out, prepared for her to say something like “You?” Instead she said, “OK, Doctor.” At first, I had her sitting on the exam table, dangling her leg off the side. But that didn’t look as if it would work. Eventually, I had her lie with her foot jutting off the table end, the board poking out into the air. With every move, her pain increased. I injected a local anesthetic where the screw had gone in and that helped a little. Now I grabbed her foot in one hand, the board in the other, and for a moment I froze. Could I really do this? Who was I to presume?

  Finally, I gave her a one-two-three and pulled, gingerly at first and then hard. She groaned. The screw wasn’t budging. I twisted, and abruptly it came free. There was no bleeding. I washed the wound out, and she found she could walk. I warned her of the risks of infection and the signs to look for. Her gratitude was immense and flattering, like the lion’s for the mouse—and that night I went home elated.

  In surgery, as in anything else, skill, judgment, and confidence are learned through experience, haltingly and humiliatingly. Like the tennis player and the oboist and the guy who fixes hard drives, we need practice to get good at what we do. There is one difference in medicine, though: we practice on people.

  My second try at placing a central line went no better than the first. The patient was in intensive care, mortally ill, on a ventilator, and needed the line so that powerful cardiac drugs could be delivered directly to her heart. She was also heavily sedated, and for this I was grateful. She’d be oblivious of my fumbling.

  My preparation was better this time. I got the towel roll in place and the syringes of heparin on the tray. I checked her lab results, which were fine. I also made a point of draping more widely, so that if I flopped the guide wire around by mistake again, it wouldn’t hit anything unsterile.

  For all that, the procedure was a bust. I stabbed the needle in too shallow and then too deep. Frustration overcame tentativeness and I tried one angle after another. Nothing worked. Then, for one brief moment, I got a flash of blood in the syringe, indicating that I was in the vein. I anchored the needle with one hand and went to pull the syringe off with the other. But the syringe was jammed on too tightly, so that when I pulled it free I dislodged the needle from the vein. The patient began bleeding into her chest wall. I held pressure the best I could for a solid five minutes, but still her chest turned black and blue around the site. The hematoma made it impossible to put a line through there anymore. I wanted to give up. But she needed a line and the resident supervising me—a second-year this time—was determined that I succeed. After an X-ray showed that I had not injured her lung, he had me try on the other side, with a whole new kit. I missed again, and he took over. It took him several minutes and two or three sticks to find the vein himself and that made me feel better. Maybe she was an unusually tough case.

  When I failed with a third patient a few days later, though, the doubts really set in. Again, it was stick, stick, stick, and nothing. I stepped aside. The resident watching me got it on the next try.

  Surgeons, as a group, adhere to a curious egalitarianism. They believe in practice, not talent. People often assume that you have to have great hands to become a surgeon, but it’s not true. When I interviewed to get into surgery programs, no one made me sew or take a dexterity test or checked to see if my hands were steady. You do not even need all ten fingers to be accepted. To be sure, talent helps. Professors say that every two or three years they’ll see someone truly gifted come through a program—someone who picks up complex manual skills unusually quickly, sees tissue planes before others do, anticipates trouble before it happens. Nonetheless, attending surgeons say that what’s most important to them is finding people who are conscientious, industrious, and boneheaded enough to keep at practicing this one difficult thing day and night for years on end. As a former residency director put it to me, given a choice between a Ph.D. who had cloned a gene and a sculptor, he’d pick the Ph.D. every time. Sure, he said, he’d bet on the sculptor’s being more physically talented; but he’d bet on the Ph.D.’s being less “flaky.” And in the end that matters more. Skill, surgeons believe, can be taught; tenacity cannot. It’s an odd approach to recruitment, but it continues all the way up the ranks, even in top surgery departments. They start with minions with no experience in surgery, spend years training them, and then take most of their faculty from these same homegrown ranks.

  And it works. There have now been many studies of elite performers—concert violinists, chess grand masters, professional ice skaters, mathematicians, and so forth—and the biggest difference researchers find between them and lesser performers is the amount of deliberate practice they’ve accumulated. Indeed, the most important talent may be the talent for practice itself. K. Anders Ericsson, a cognitive psychologist and an expert on performance, notes that the most important role that innate factors play may be in a person’s willingness to engage in sustained training.
He has found, for example, that top performers dislike practicing just as much as others do. (That’s why, for example, athletes and musicians usually quit practicing when they retire.) But, more than others, they have the will to keep at it anyway.

  I wasn’t sure I did. What good was it, I wondered, to keep doing central lines when I wasn’t coming close to hitting them? If I had a clear idea of what I was doing wrong, then maybe I’d have something to focus on. But I didn’t. Everyone, of course, had suggestions. Go in with the bevel of the needle up. No, go in with the bevel down. Put a bend in the middle of the needle. No, curve the needle. For a while, I tried to avoid doing another line. Soon enough, however, a new case arose.

  The circumstances were miserable. It was late in the day, and I’d had to work through the previous night. The patient weighed more than three hundred pounds. He couldn’t tolerate lying flat because the weight of his chest and abdomen made it hard for him to breathe. Yet he had a badly infected wound, needed intravenous antibiotics, and no one could find veins in his arms for a peripheral IV. I had little hope of succeeding. But a resident does what he is told, and I was told to try the line.