by Cap Lesesne
I couldn’t see how I might spend the rest of my life witnessing the deaths of so many children; I simply couldn’t. Of course, I could be a pediatrician and not work at a children’s hospital that specialized in cancer. (It should be noted that, thanks to medical advances in the last generation, certain childhood cancers, particularly leukemia, have become far more treatable, at Duke and elsewhere. Duke was then and remains today one of the world’s top pediatric cancer clinics.)
But it also seemed like running away. It seemed an acknowledgment that I could go only so far, no further. And that bothered me.
Bothered me? It destroyed me.
I was surrounded by Southern pine and dogwood, but the trees that evening smelled like death. Everything did. Everything around me was dying. And everyone. I managed a bitter smile thinking that, from the moment I’d arrived on campus, death was lurking. On the first day of sign-up, I stepped up to the registrar and said brightly, “I’m here to enroll!”
The lady behind the desk looked up at me, quizzical and pained. “Have you heard? The King is dead.”
“What?” I asked.
“Elvis died,” said the registrar. “The King is dead.”
What is wrong with me? I wondered now, sitting on the steps of Duke University Hospital.
I’m a doctor who can’t handle death? Does this mean I’ll make a rotten doctor, no matter which kind of medicine I go into?
What else is therefor me to do?
Sadly, there was then, and remains now, a great need for young doctors to work in children’s cancer hospitals. But there was just no way I would be one of the courageous men and women to do it.
My feeling of desolation, sitting alone on those steps, did not make me a rotten person, or even mean I would not succeed in medicine. I think I understood that. But it depressed me to think I didn’t have it in me to be the doctor I’d hoped I could be.
Love Affair
I never forget a face. Of all the faces I have laid eyes on in my life, hers may be the most unforgettable.
And when it was all over, I had fallen in love.
Use any of the clichés – struck by lightning, head over heels, shot through the heart – because they all apply. One day my life is heading in one direction. Sixteen hours later it’s headed in a completely different, and absolutely unwavering, direction.
It happened at two in the morning, a sweltering July night in 1979, in Durham, North Carolina, in the trauma room of the ER, at Duke University Medical Center. Two surgeons and the ER staff were hunched and busy over a dying woman that night.
In saving one life, they also managed to transform a second one.
She was an all-American volleyball player. Earlier that night, the car that she and her boyfriend were driving had hit a tree. She flew through the windshield. She was spirited to the emergency room – and I do mean spirited, because not a person who saw her being rushed on a stretcher into the triage area in the ER expected her to survive the night. The ER team began to work on her, but the extent of the damage was historic. Her face, in particular, was crushed beyond recognition.
I knew nothing of all this. I was home, sleeping, dead tired from another night of medical school. I was three days into my newest rotation, surgery.
The phone rang. Bolting upright – a skill that after a while becomes reflex, once you give your life over to doctoring – I saw my alarm clock read just past 2:00 A.M.
“What?” I barked.
It was another intern, a friend on call that night at the hospital.
“Cap, man,” he said with wonder in his voice. I was half-asleep, though, and couldn’t detect anything besides an unwelcome wake-up call.
“I’m sleeping,” I said.
“Get your ass over here,” he said.
I threw on my pants and white coat and walked, bleary-eyed, the quarter mile to the hospital. In the all-American, five-foot-ten volleyball player, I witnessed the most devastated physical presence imaginable. Every major bone in her face was broken. Her eyes were dangling from their sockets, each one trying to peek into an ear. Every tooth was broken. Her nose was crushed in the middle. Her scalp was nearly torn off. She had multiple lacerations. Blood was everywhere. It was hard to determine what remained of her face, and if what was left could even be reconfigured as human anymore.
For the next sixteen hours – the first couple in the ER, the last dozen or so in the OR – I stood right beside a plastic surgeon and his resident and watched as they worked with a team of ophthalmologists and oral surgeons to reconstruct the woman’s face. Calmly, and with ease, the surgeons used wire and high-speed drills to refit the bone back around her eyeballs. If the doctors were off by even one millimeter, they could blind her.
At one point during the surgery – we’d all lost track of time – the resident shook his head. “Hell of a way to make a living,” he said gently.
The girl recovered.
I, however, would not. The next afternoon, when I finally walked out of the OR after a night of standing almost frozen, of no sleep, of staring intently for a dozen hours straight at this miracle of skill and medicine and care, I was not exhausted but exhilarated.
Plastic surgery!
A branch of medicine where you take a patient in some type of distress, and you make him or her significantly better … and you can actually see the immediate improvement? Just as powerful to me, though, was that it required such an impressive arsenal of abilities: concentration; physical dexterity and stamina; the intellectual alacrity to balance form and function; an awareness of aesthetics, structure, symmetry; a gift for understanding the human psyche and its frailties; compassion and candor and discretion.
(My initial love for the field, typical of most plastic surgeons, had nothing to do with cosmetic surgery. Our first exposure to the field is exclusively reconstructive surgery; observing and doing cosmetic surgery only comes later.)
After sixteen hours of watching a life and a face restored with the most amazing technical grace, I had found something that was miraculous for the individual patient, beneficial for society, and fulfilling for me. Plus, I felt – yes, deep in my bones – that I’d always had aptitudes that could now be exploited for just this pursuit: a love of aesthetics, a deeply visual memory. Even my ability to concentrate for hours at a time, honed while building models and sculpting clay as a kid because I was inept at sports, was now morphed into a virtue.
The day after watching the volleyball player return from the dead, I stood outside the medical school administrative office, waiting for the door to open so I could immediately change my course schedule for the coming year and focus on plastic surgery. Once I was done with that, I canceled all my vacation and holiday plans.
For the next two and a half years.
I finished the four-year program at Duke in three. I had high hopes. I was going to be a great plastic surgeon, like my mentors.
After what I had seen that summer night, a night that had unknowingly begun for me when a beautiful, athletic girl had hurtled through glass and struck a tree until she was shattered, only to be put back together again miraculously, there was no way in the world I could spend my life doing anything else.
My relationship with Tory consisted of our seeing each other every second or third weekend, alternating between Princeton and Duke. Among the med students, I was one of the few men in my class committed to a long-distance relationship. There was lots of romance between male and female doctors-to-be, and lots more young doctor and nurse couplings, too. Not that I needed to be spoken for to keep me from being distracted by the nurses and female residents. That it had become impossible for me to think of anything besides medicine should have been a tip-off to Tory, and to me, too, that making a relationship work would, now and for a long time to come, require me to be a very different person from the one I was becoming.
A few months into my surgical rotation I did my first appendectomy, as my professor stood across the table. It was the first time I’d made an inci
sion into a living human being. This was not a sleeping dog or a cadaver. It was an out-of-body experience.
You pick up the scalpel, run it along the lower abdomen, and right away notice the particular pressure that must be exerted to open skin and expose the underlying tissue. Your fingers send messages to your brain, and vice versa, a feedback loop, so that you can adjust to this holy cow you have no clue what you’re doing. No matter how much you have read or observed, nothing can compare to what you’re going through now. There’s nothing like the real thing.
Blood is coming out. I’m scared.
Do not look up at Dr. Young. He’s right across the table watching you but you must focus on this, your fingers and brain working together, guiding you to go a little deeper…. Put your finger there, Lesesne, that’s it … any moment now you should be wetting your pants …
The more surgery I performed or assisted on, the more convinced I was that I wanted to be a plastic surgeon. Whereas my father got excited about the prospect of my being a doctor, and even more when I said I wanted to be a pediatrician, he was less thrilled about my decision to be a surgeon, and less so still about my being a plastic surgeon (though he would eventually come around). To me, plastic surgery offered an intellectual appeal that other types of surgery did not – the planning involved, the attention to detail, the fact that the entire body is the canvas, not just one organ. It’s a younger surgical discipline, too, so a sense of discovery seemed more possible. Patients get well. They don’t die. The aesthetic challenge appealed to me. I wanted to help people, to make their lives brighter. At this point I knew myself well enough to recognize that I did not have the emotional constitution to deal with what (for example) a cardiac surgeon must.
When my medical training at Duke ended, Dr. Sabiston – my mentor, the finest teacher I will ever know – offered me the chance to stay on as a resident. I’d learned so much at Duke, but I respectfully turned him down. I’d already been accepted as a surgical resident at Stanford, a top program. I treasured the doctor’s offer as the penultimate compliment from him to me.
I say penultimate because he would pay me the ultimate compliment years later, when a woman showed up at my Park Avenue office to consult about a face-lift. When I asked how she’d heard of me, she said her longtime friend Dr. David Sabiston down in Durham had said I was the best.
As I left North Carolina, I hit the gas, breaking the speed limit in every state I crossed, so I could get to California as fast as I could and start being a surgeon.
Blood Everywhere
June 20, 1980, I graduated from medical school. Two hours later I was speeding westward, all my belongings stuffed into my blue Datsun 310 hatchback. The trip took sixty hours. I slept in the car. As I crossed the middle of the country, rocketing toward my apprenticeship in one of the most prestigious surgical programs in the world, I thought:
I’m scared.
I don’t know whether I’ll make it through. Will I screw up? Will I kill somebody?
I rocketed past sights I’d never seen before, vistas that took my breath away – the Great Salt Lake, the Sierra Nevada – but as I neared California, I felt, mixed in with my excitement, a sense of solitude that bordered on loneliness. Out here under the big Western sky, I was far away from family and far from Tory, who had started law school in New York. Fair Acres Road and the leafy streets of Grosse Pointe were only a thousand miles behind me, but it might as well have been a thousand years.
I hinted to the surgery registrar – okay, more than hinted, begged – not to start me on the cardiac surgery unit. How about urology? No night call. An easy start. Just please don’t make it cardiac, not to start with. I would have to cycle through cardiac at some point, I knew, just like every surgery resident, but it was legendarily awful – long hours, physically and psychologically demanding, the toughest rotation around. I was simply hoping for a little bit of time to adjust, maybe start with something a little less taxing. Even neurosurgery would have been a relief. I hadn’t had a light week in three years.
They posted the schedule for all the first rotations.
LESESNE, CAP: CARDIAC.
One door closes. Another one opens.
So I wouldn’t get a breather. But it was in the cardiac surgery rotation that I really learned to be a surgeon, and I suspect the same is true for most surgeons. That first month was the most intense, exhausting, frightening, chest-thumping of my life. I started out feeling stupid. Knowing nothing. Before getting too frustrated, though, I relied on all that solid Duke Medical School training to help me.
Sort out the problem. Think it through.
And then a funny thing happened: I liked cardiac. A lot. Having first dreaded it, I now found it so invigorating, and my surgeon mentors so likable and inspiring, that I thought I might become a cardiac surgeon. The team I worked under was first-rate: Several of them are chiefs of surgery at top hospitals across the country today. None was more encouraging to me, and on top of his game, than Norman Shumway. I worshiped him. My very first day on the job – June 28, a Saturday – I showed up for 6:30 A.M. orientation in my white coat. As I walked down the hall, Dr. Shumway approached and did something no one had ever done before.
He called me Dr. Lesesne.
At the orientation, we new guys were all told, repeatedly, that if we found ourselves in any kind of trouble or confusion, we were to call for help. That was the main lesson for the day. Otherwise, it was reasonable, even quiet. I left the hospital at 6:00 P.M.
Hey, this isn’t too bad, I thought. Maybe cardiac wasn’t always brutal.
The second day I was given something to do. A patient – a lawyer from Ogden, Utah, scheduled for a heart bypass the next day – had come in for his pre-op visit, and Dr. Shumway, busy with other patients, instructed me to “work up” Mr. Jensen – get his medical history and examine him (blood pressure, heart, lungs, etc.). But as soon as I walked into the examination room and explained to Mr. Jensen why I was there, he looked disgusted. Sensing how green I was, he insisted I fetch Shumway.
I obeyed, found the doctor, and brought him back to the exam room with me.
“Dr. Shumway,” said Mr. Jensen, “I’m not letting some high school kid examine me.”
I meekly opened the door and started to shuffle out, but Dr. Shumway put a firm hand on my shoulder. “Stay here, kid,” he mumbled. I would learn that Dr. Shumway mumbled almost everything, in or out of the OR.
Dr. Shumway turned to the patient. “Mr. Jensen, Dr. Lesesne is my associate. If you don’t let him examine you, I’m not operating on you. So if you’re not up to being examined by him, you might as well get the hell out of my hospital, okay?”
“Okay,” said Mr. Jensen.
“Good,” mumbled Shumway, and gave me a pat. “So Dr. Lesesne will examine you, and I’ll see you on the table tomorrow morning.”
“Okay,” said Mr. Jensen, nodding obediently.
In surgery, particularly cardiac surgery, there is no such concept as zero to sixty. You start at sixty, put the pedal to the floor, and leave it there. That’s what happened during my very first operation at Stanford.
I was working under Dr. Shumway and Alex, his chief resident. A banker was getting a heart bypass. Such an operation is a big deal. Critical vessels to the heart are obstructed. People die.
The actual bypass – an unobstructed vein “harvested” from elsewhere on his body (in this case, his leg) – would be sutured on the outside of the heart, circumventing the obstruction.
In a few moments, we would be stopping the banker’s heart and transferring pumping responsibility to a machine, while the doctors sutured vessels.
I was assigned to make an incision in the leg, starting at the inner groin and going down to the ankle. To free up the vein we wanted – the saphenous vein, which looks like a pipe with multiple branches – Alex cut all around it, then tied off the little branches leading out of it (called perforators). This stopped the bleeding. The saphenous is the perfect vein for a bypass: long,
continuous, dispensable.
While Dr. Shumway placed tie-over sutures in the aorta to allow the bypass tube to be inserted, I began my lowly job of suturing up the skin on the leg. Alex occasionally glanced at me. In the last year of his residency, he was far more experienced than I.
“Dr. Shumway,” the chief resident said casually, “he’s screwing up the leg.”
I’d left some gaps in the skin, which would require adding a few more sutures.
“We’ll deal with it later,” mumbled Shumway. “Duke guys are slow learners,” he teased.
Surgical humor. Everything was going nicely.
Dr. Shumway lifted the patient’s heart to get access to the left anterior descending artery. As I continued to sew, I heard Alex say, “Holy shit.”
I looked up. Alex, whom I had always admired for his cool demeanor, was frozen. His face was chalky, and his eyes, over his mask, had gone wide. I looked to see what he was staring at.
It must have been the blood pouring out of the patient’s chest. A Vesuvius of blood.
There was a tear in the heart. The back wall of the heart had come apart when Dr. Shumway had gently lifted it to sew.
The patient was now bleeding and dying before everyone’s eyes. I was frozen.
“What do we do now, chief?” Alex croaked.
“Alex,” said Dr. Shumway, whose hands had not stopped moving, “this is what separates the men from the boys.”
Blood was on the OR floor. Blood had soaked through the surgical towels surrounding the patient’s chest. The patient had flatlined.
Dr. Shumway mumbled to switch the patient onto the bypass immediately, skipping normal preparatory steps such as checking the pump volume or asking about the readiness of the scrub tech – an OR assistant who had been with Shumway for years and probably knew the doctor’s rhythms better than he did himself. Dr. Shumway had to assume that everything would work.
