By Will Smythe
When I was a surgical resident, I once won a teaching award from the students at the school where I was training. It was called the “Pearls” award, and those that were chosen were asked to deliver a ten-minute lecture on something that they deemed important to those, the students, learning the art and science of medicine –we were supposed to share, as we say in medicine, a “clinical pearl”.
An actual medical research paper was written just a few years ago on the topic of the clinical pearl, and it was defined by the authors as follows:
“Clinical pearls are best defined as small bits of free standing, clinically relevant information based on experience or observation. They are part of the vast domain of experience-based medicine, and can be helpful in dealing with clinical problems for which controlled data do not exist”.
That’s a fairly long-winded explanation for what I would describe, a bit more simply, as “advice”.
In any event, I was excited about the award, but didn’t really know what to discuss. Actually, I was fairly apprehensive – there was only one resident trainee that received the award each year at the school, and several established faculty members – all of whom had much more of an opportunity in the “vast domain of experience-based medicine”. To make it worse, the other awardees were not junior faculty. A quick review of the those listed on an announcement sent out a few weeks before showed that the others were all “Professors” – most considered national, if not international experts in their respected fields.
I, on the other hand, was only halfway through my first Surgery textbook, and I was still pulling out the anatomy atlas fairly frequently before surgical cases, where as the most junior member of the surgical team I demonstrated daily the many reasons for my own acclaim – cutting sutures, placing bandages, making sure that the postoperative orders were written legibly, and keeping track of patient’s room numbers.
I fretted for several weeks over the topic that I would discuss. It had to be something that the students would enjoy, and that the faculty illuminati would be impressed by as well. I imagined in more optimistic moments (fleeting, rare moments) that the professors would all smile, and frequently shake their heads with approval as I spoke, and that several students would come up and mob me at the podium, with looks of adulation and perhaps envy – all obviously clamoring… no, hungering for more “pearls”. I settled on a concept that I thought would accomplish both – a lecture entitled “The Importance of Observation of Surgical Patients”. I actually gave a lecture during which I suggested, with what I thought was a great deal of earnest erudition that it was important to look at patients before operating on them.
Shockingly, it didn’t go as well as I had hoped.
It was convention for the resident awardee to speak last, so I followed the other speakers’ lectures on topics that sounded to me a lot like: “How You Can Discover The Cure For Cancer, Like I Did”, and “The Importance Of Humility While Receiving The Nobel Prize” with my profound discourse on “Hey, Make Sure You Look at Your Patients”.
The professors, all looking to me like assorted versions of Buddy Holly with a bad attitude, sporting 1950’s haircuts and heavy black-framed glasses, just sat motionless and scowled for the entire ten minutes, and the medical students scurried out of the back doors of the auditorium when I was finished like mice in the kitchen when the lights come on.
Despite this and a few other notable miscalculations, I eventually completed residency, and got to the point in my career where someone else cut my suture, placed bandages on my patients, made sure that post-operative orders, were accurately keyed into the computer, and told me where to find my patients on rounds. Interestingly, despite my unfortunate lecture experience, I never really let go completely of the notion that a lot can be learned from observing patients – by seeing them before they see you, or our name-badge and white coat, and then by just “paying attention” to details as you interview and examine them.
In the years following that lecture, as a more senior resident responsible for surgical consultations in an inner-city emergency room, I learned that a peek around the curtain could yield a great deal of useful information. I learned that it could at times jumpstart the process of making a diagnosis and plan for action well before the patient’s body was passed through the CT scanner, or a thousand blood samples were collected and analyzed. There was, as it turned out, a lot to be learned from a “surreptitious stare”.
Was the patient malingering? Did he begin moaning only when I entered the room, happily humming a tune beforehand? Did she get out of her chair, and lean over easily from the waist to grab something out of her purse and then lie back down on the gurney before I drew back the curtain, at which time she claimed that her “back was hurting too bad to move or bend over”, and that she was “too weak to stand up”?
Was the patient lying ply-board stiff and still on the stretcher with knees slightly flexed, or literally writhing in pain like a snake on a hot skillet, unable to find a comfortable position? The former might suggest inflammation of the tissues lining the abdominal cavity – maybe peritonitis due to a ruptured appendix or colon diverticulum, and the latter – colic, the acute obstruction of a hollow organ caused by an irresponsible loop of bowel kinking on itself, or an indifferent stone wedging itself somewhere in the gall bladder.
Did the patient appear… depressed? Alone? Unkempt? Angry? What was the patient wearing? An expensive suit? A fur coat? Dirty, tattered rags? Scrubs? A football uniform? Knowledge of any of these could direct the tone and line of initial questioning, and focus the exam. It could actually begin to narrow a differential diagnosis before the patient was even aware of my existence. Having an idea about the constellation of problems ahead of time could also allow me to be more efficient, and at times, at least an opportunity to be more empathetic about whatever the patient might be experiencing.
As I found myself involved in more and more specialized care, and taking fewer trips to the emergency room to evaluate acute conditions, I had less opportunity to practice this form of medical voyeurism. However, I still caught a glimpse of patients from time to time in the clinic where I evaluated them for elective cancer surgery before they had a chance to see me – and such was the case with Anne.
The clinic had a large rectangular common area, where the doctors would review Xrays and records, delimited on both sides by long, linear hallways of examination rooms. I was sitting at my workstation in one of the corners of that space between patients, and happened to turn and look through an open door – across the hall and into an exam room. I watched as a new patient was led there, and deposited by the clinic nurse. She sat down in a chair next to the small working desk, facing the examination table on the other side of the room, her right side toward me.
I began to form an opinion about several things, as I watched. She was older… perhaps well over seventy. She sat down carefully in the chair after the nurse departed, but with no evidence of musculoskeletal compromise, and folded her hands in her lap with no evidence of a tremor. She was trim, but not too thin, and certainly not emaciated, which could be consistent with a number of chronic conditions, and at times, a cancer that had advanced too quickly to intercede surgically. She was neatly dressed – wearing a pressed, perhaps starched, white open-collar blouse, khaki pants, and dark flats. Her dress suggested that if not well-to-do, that she was at least “comfortable” financially. Her shoes and handbag were new, and stylish, but not flashy. She slumped her shoulders slightly forward, and lowered her head, eyes open. Her hair was short and simply styled – grey, with streaks of white here and there.
I continued to watch her – she still oblivious to me for now, from more than forty feet away. Actually, she seemed oblivious to just about everything – I noticed that the nurse passed by the open door three times, two of them leading other patients or family members in one direction or the other, but she never once looked up in curiosity, or perhaps just in response to the nearby motion, as we humans are apt to do. She just sat still, staring at the floor.
She looked, or perhaps seemed very, very alone. I wondered if she were widowed. I had taken care of very few widowed men in my career as a cancer surgeon, but too many widowed women to actually count – it was just the way the odds settled out, at least for her generation. It was also possible, certainly, that her husband wasn’t able to come with her for some reason, but I found that to be less common above the age of seventy. The men either came, even if they required assistance, or they were no longer around.
Her posture, disinterest to her environment, and her inanimate state suggested either pain, fatigue, or worse – the habitus of depression. If she were lowering her head and leaning forward due to pain, it struck me that she would have closed her eyes, and not kept them open. It is admittedly quite difficult to discern fatigue from depression – they are close friends, and are often seen huddling together in the corners of cancer clinics. However, the fact that she was sitting in a lung cancer surgeon’s clinic certainly enhanced the possibility that she had heard some bad news from the doctor that sent her here, as most had – I opted for depression.
The time came for me to see her, so I walked over and knocked on the doorframe.
“Hello,” I said, cheerfully, “can I come in?”
She turned her head quickly, sat up straight, and set her purse on the floor next to her chair.
“Of course,” she replied, the grimace on her face temporarily becoming a smile. A forced smile, I pondered.
“Mrs. Johnson, Anne Johnson?” I asked.
“Yes… yes that’s me,” she replied, looking down for a moment before she answered and again grimacing, as if she were searching her mind to make sure that she was indeed this person, or perhaps suddenly bothered by some thought or feeling that I had brought to her mind.
“Is everything okay?” I asked.
“Yes, yes,” she replied quickly, looking up and smiling again, “it just struck me how infrequently I had been called Anne over the years. I always know that it’s something official when I am – you know, called Anne – a trip to the doctor, or a lawyer, that sort of thing.”
At this point, I would normally have just opted for “Ms. Johnson”, but since she had given me an entre, I took it.
“What do you prefer to be called,” I asked, “if not Anne?”
Her face, relaxed slightly for the first time since I walked in. She leaned back in her chair a bit, but kept her proper posture. “My parents… well, my father… who adored me, called me Annie.” She stopped, and shook her head up and down as if answering in the affirmative to a question she had posed to herself, “you know, I adored him too.”
She then looked up at me, with a slightly surprised expression, her eyebrows lifted ever so slightly. “Funny,” she said, “I’m seventy-seven, and a little scared. It just struck me that I wish my father were here now with me to deal with this. Of course, he’s been gone for fifty years, so it’s silly to even think about it, isn’t it? I haven’t had this feeling for a long, long time.”
“No,” I replied, “I lost my father when I was a teenager. I have the urge to talk to him every now and then as well, for a number of different reasons, and especially when something’s upsetting, or troubling me – I understand.”
“Teenager?” she countered, “Poor dear… your mother? How about brothers and sisters?”
“No ma’am,” I replied, “my mother died around the same time, and I was the only child.”
She looked at my face tenderly for a moment, like a mother would, it occurred to me.
“I had two sisters and a brother,” she offered, sadly, as if anticipating the next question, “but they’re all gone now as well…. all gone” She slumped forward again, and gazed at the floor.
“Your husband?” I asked, trying to slip the question in behind the previous one, like a car running through a parking gate after the one in front of it, without stopping or waiting its turn.
“Gone,” she said, flatly, “gone too.”
“Did you have any children?” I asked.
She sat back again, looked down her lap, and squinted her eyes nearly shut, as if trying to keep a thought or a memory from forming completely. She clenched her hands together tightly, her fingers and wrists trembling with the effort.
“Yes… of course… I do. I mean, my late husband and I did. A boy. A son. Yes, my… our, I guess, son, Robbie.”
“Does he live nearby?” I asked.
“No, they live in Chicago,” she said – her hands kneading one another now as if she were working cold dough that was stiff and requiring a great deal of force to deform. Her fingers blanched with the effort. She turned and looked past me, out the window.
“How about grandchildren?”
“Two,” she replied, tersely, “two… a boy and a girl.”
“Do you ever get to see them?”
“No,” she said, somewhat forcefully, still looking out the window, and then softened when she realized her tone, looking down at her hands again, “uh… well… no. My son… My son, you know, he’s very busy with his work, so busy. And they live in the city… no place for me to stay if I were to visit. Real estate, you know… so expensive there, right on Lake Michigan.”
I went on with the “medical” interview at this point, asking her a series of questions about her condition, and then examining her. Outwardly, there was really nothing of notice – her medical profile wasn’t too bad for a woman her age – except, of course, for the lung cancer.
I had reviewed her CT scan and other X-rays before coming in to see her. She had a large tumor, about the size of a softball, in her upper left lung. The size of the tumor wasn’t the thing that worried me; however – I had removed larger ones. The thing that I was most concerned about was how close it was to her aorta – the body’s “main” artery. The aorta is a inch and a half wide blood vessel that leaves the left side of the heart, and is the conduit through which all of the newly oxygenated blood flows to the organs – more than three liters of the life-giving fluid every single minute.
I couldn’t tell on the CT scan whether the tumor was just jammed up next to the aorta, or actually involving it – or in other words, whether it was touching, or had invaded, or grown into the wall of the body’s most important vascular thoroughfare. However, there were two other potential problems. The first was the fact that the tumor was high up on this vessel, near to where the large branches to the left arm, and left side of the brain originate, and in addition, the vessel itself wasn’t normal. Some patients at this age develop atherosclerosis of the aorta – a condition whereby the wall gets thickened with debris, and can become layered with rock-hard calcium. Her aorta was badly diseased in this way.
So, the conundrum would be what to do if the aorta was in fact involved. In a younger patient, we would consider cutting a piece of it out and repairing it if necessary to get the tumor out. However, trying to remove a segment of her aorta and repairing it would likely not be possible. Imagine trying to sew together the ends of a wet toilet paper tube that is lined with a thin layer of porcelain back together, after the wall has been cracked in a thousand places, and the tube torn into two separate pieces.
I suggested that we order another test – an MRI, to see if we could get a better idea of whether or not the tumor was actually invading the vessel wall, and she agreed. The test was obtained, and we still weren’t sure. I asked her to come back into clinic to see me to discuss this several days after our intial visit.
“I still can’t tell whether or not your aorta is involved,” I reported to her, “the MRI isn’t conclusive, but it is suspicious – the tumor may be growing into the wall of the aorta – the big blood vessel that comes out of the left side of your heart.”
“What does that mean?” she asked.
“Well, we won’t know until we get into the operating room, but if your aorta is involved with the tumor, we would either try to leave a little tumor behind as possible, to radiate afterwards, or simply stop if necessary, and not try to take the tumor out at all. I hesitated for a moment, and then continued, “the other issue that you need to be aware of, despite how difficult it is to consider, is that if we were to injure your aorta badly in the process, it would likely not be something we could easily fix, or maybe even fix at all.”
She unclenched her hands, and smoothed her pants legs down to the knees and back again with her palms, “You mean I could die, right?”
“Yes ma’am…” I tried to soften my voice, to lessen the impact, knowing that it probably never really softened the blow of this information, “yes, that’s a possibility. I don’t think there is a really high risk of that, but I just won’t be able to tell until we are in there. How do you feel about all of that?”
She lifted her purse off of the floor, placed it in her lap, and began to absentmindedly fiddle with the straps.
“I was thinking about that discussion we had about my name the other day,” she said.
I thought that perhaps she was trying to change the subject, or that perhaps she was a little senile? Did I miss that the first time we met? This was a bit of a right turn, considering what we were discussing at the moment.
“Yes?” I inquired.
“I told you that I have only been called Anne a few times in my life, and that my father called me Annie.”
“I remember,” I answered, ceding her what time she needed. Perhaps she was just stalling – my previous comments, and the open-ended question of what she “thought about all of that” too difficult to respond to immediately.
“Yes. Well, my husband called me my favorite name, and that’s Anne-Marie. Would you consider calling me that instead of Ms. Johnson?” She looked at me hopefully, and for the first time I noticed how pretty her eyes were, a light blue-green color that radiated out from the center like a child’s pinwheel.
“Sure,” I said, and waited silently for several seconds before returning to the question of whether or not to go ahead with the operation – still hanging in the air like a gnarled garland between us, “so… what do you think about proceeding, knowing that we might not be able to fix that blood vessel if it were injured.”
“Doesn’t seem I have much choice, does it?” she asked.
“You always have a choice,” I replied gently, “this is a decision that I am willing to help you make, but it has to be yours.”
“I wanted you to call me Anne-Marie, like my husband did because I like the way you are honest with me. Bill… my Bill, was one of those rare honest lawyers,” she chuckled, “and he was honest with me too. We were honest with each other.”
The skin on her face was wrinkled appropriately for a septuagenarian, especially around her eyes and mouth. For a moment; however, I caught a glimpse of her as a younger woman, Bill’s young wife, perhaps, or her absent son’s loving young mother – her features softened, and her grey hair, for a moment in my mind, became brunette.
“Thank you, Anne-Marie,” I replied, “I would be happy to call you that… thank you for the honor of allowing me to call you that.”
She smiled, and reached out and took my hand between hers. Her hands were wrinkled as well, and dry, but warm.
“I’ve done everything I want to do here,” she said softly, but very confidently, “but would like some more time if I can have it… No one wants to die, but we all know we have to, at some point. Let’s go ahead, and you do what you think is best. If it comes down to something questionable or difficult, just you do what you think is best. I am ready for what ever comes.”
“Will your son, or anyone else be coming on the day of surgery,” I asked.
She drew her hands back out of my loose grasp, put them in her lap together, and began to knead the stiff dough of remembrance once again.
“I’m not sure… I don’t know,” she said, “I… I will have to let you know later.”
“It’s fine,” I replied, “I’ll check in the waiting area afterwards, and speak to whomever comes – family or friend. No big deal.”
Anne-Marie’s case was scheduled for two weeks later.
I walked into the operating room where my resident trainee, and the nursing staff had already positioned Anne-Marie, prepped her skin with an antiseptic solution, and placed disposable paper drapes on her body. A two-foot square area of skin was exposed where we would make the incision.
The CT scan was up on the big screen monitor in the room, and I manipulated it, looking at the tumor from as many angles as possible – I was looking at Anne-Marie’s chest in cross-section, ten times its normal size. I always looked one final time at the images in the operating room before starting – in this case looking one more time at what we were going to be up against – perhaps hoping that the picture would look different from the last time I viewed it. The fact was; however, that the images never looked any better in the operating room – and at times, worse.
“That’s a big one,” my resident, a young promising woman that was considering vascular surgery as her career path after general surgery training, “and in a rough place.”
“That’s right,” I replied, and asked the circulating nurse to call one of my cardiac surgery colleagues into the room – I knew he had a case down the hall from me, but hadn’t yet started.
He entered and I explained Anne-Marie’s case to him. He looked up at the CT scan.
“What would you do if you found the aorta involved in that area?” I asked him, “would you be willing to do a resection and some sort of repair?”
He shook his head and rubbed his hand on his chest, absentmindedly, as if he were contemplating his own anatomy beneath.
“No…, impossible,” he replied, “You would have to replace the entire thing, including those arch vessels branching off to the head. She probably wouldn’t survive it, especially in addition to a big cancer operation.”
I thanked him, and he left to go and deal with his own challenge for that particular day. The resident had been standing nearby and listening.
“What are our chances?” she asked.
I replied, chuckling a little but not smiling – a nervous response with no associated humor whatsoever, “our chances are excellent… but we’ll see about Ms. Johnson’s in a little while.”
The familiar drumbeat steps that start any case began – the first few moves were almost always the same first verse of the same song, with a predictable rhythm. We made a large incision under the left shoulder blade and down through the muscles of the chest wall to the ribcage. We then divided the muscle between the ribs, and placed spreading retractors between them, cranking them open slowly to expose what lie beneath. This is where the tune always changed – each patient had a different second verse once you were inside, and at times, the music became unfamiliar, and unpleasant.
The tumor was large, as expected. The resident placed her hand into the upper chest and felt it. “It doesn’t move,” she said, “it’s at least stuck to the aorta,,, but I can’t tell if it’s invading.”
I took my turn palpating the area, and agreed.
“Let’s see what we can do,” I said, confidently.
I wasn’t confident.
We started at the front of the tumor and in a short period of time, ran into a place where the tumor and the wall of the aorta were fused, and our progress stopped. One of the things you learn in cancer surgery is to keep moving – if your advance is stopped – don’t retreat, just try to move troops in on the flanks, as you might be able to weaken the opposing army by coming from a different direction. We tried from the top – initially we made progress, but eventually we again met the same resistance.
“Let’s divide the upper lobe from the lower one,” I suggested, “see if we can come from bottom up.”
The lung has two lobes, or anatomic subdivisions, on the left side of the chest, and there is often some tissue attaching the two in the area where they separate – an area that we call the “fissure”. In some people, the fissure is “complete”, and the two lobes separate with no effort, exposing the arteries and bronchi, or breathing tubes, branching to each one. At other times, the two lobes can be completely fused, requiring that we divide the tissue to expose the structures beneath. Anne-Marie had a small amount of bridging lung tissue holding the two lobes together in one area. We used a surgical stapler to divide that, exposing the bottom side of the tumor.
Although we were both leaning in over the incision, I was working from an angle, standing in front of the patient, that made it difficult for the resident to see exactly what I was doing. She pulled the lung gently upward, toward Anne-Marie’s head, from her position standing at the patient’s back, and I worked with my scissors beneath and below.
Suddenly, there was a large, forceful gush of blood onto the back of my hand – it felt as if someone had been crimping a garden hose near it’s open end, and had suddenly let the kink out. I quickly shoved my entire hand in over the area, and when I did so, the resident pulled a little harder on the lobe, thus the tumor, and the aorta – and the calcified fragile vessel cracked open like an egg. I grabbed the suction device and shoved it into the now garishly large opening. The resident knew what it meant. She stared at me wide-eyed and unblinking as our gaze met for what seemed like several minutes, but in reality was less than a second – a great deal of information and emotion can be transmitted by the eyes, and quickly, despite the fact that all other facial features are obscured in the operating room.
“The suction canister is filling up with blood, rapidly!” the circulating nurse yelled out.
“Send for blood, stat!” the anesthesiologist at the head of the table replied, “Blood Bank! Stat!”
“No!” I yelled back, and then, more softly, as the room became completely silent, “no… don’t send for blood, please.”
I looked over the curtain at the anesthesiologist. He had both hands on the paper drape, suspended between two IV poles, the “curtain” that separates the anesthesiologists from the operative field, pulling it down and leaning anxiously in toward me over Anne-Marie’s head, ready for my next request. His body was like a coiled spring – still reacting to the shocking sight of a liter of blood escaping into the suction system in a matter of seconds.
The suction catheter vibrated in my hand, due to the large amount of fluid flowing past at such a high rate… her blood, her life, and perhaps her soul moving swiftly and efficiently out of her body, through the clear loops of rubber tubing, across the operating table, off the bed, and into the large plastic canisters which were attached to the wall suction source nearby. My resident stared silently at the tubing, and the nurses – at the filling canisters.
I looked past the anesthesiologist at the electrocardiogram tracing displayed on the anesthesia machine. Anne-Marie had already lost enough blood that her heart was beating abnormally – an arrythmia. It was already failing. A symphony of beeps and alarms had begun – sounds that usually were life-saving rather than death signifying. They were signaling the arrythmia, in addition to the dropping level of oxygen in her blood, and her plummeting blood pressure.
“Just turn off the monitors, Tim, please… just turn them off.”
After we had closed up the incisions, and cleaned Anne-Marie’s spent body, I went down to the operating room waiting area to take care of the inevitable, and at times dreaded, next task. I walked over to the receptionist, and asked for her to call the family of Ms. Johnson.
“Excuse me, doctor?” she replied
“Ms. Johnson…, Anne Johnson,” I said, “Annie? Anne-Marie Johnson?”
“Oh yeah, doc…” she replied, taking a sip from her soda can, and looking at the computer screen in front of her, “we’ve been looking for someone all morning for that patient, but no one’s come around. Looks like she came in alone.”