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.
“Pump on,” said Shumway.
The bypass pump whirred on. The bleeding stopped.
A machine was now pumping blood to the outer vessels of the patient’s heart, although the amount needed to replace what had been lost was staggering.
Plus, the heart was still damaged. If it wasn’t repaired soon, the patient would never leave the OR table alive.
Dr. Shumway called for a 4–0 prolene suture. The scrub tech had already slapped the right suture into the doctor’s palm. Dr. Shumway, the smoothest surgeon I have ever seen, deftly began to repair the torn heart with the two prolene sutures. His fingers were moving fast, back and forth, back and forth, gently, sewing, tying off perforators. The concentration and skill were incredible. Alex and I stood motionless. Dr. Shumway’s fingers kept moving.
Finally, they stopped. Shumway barked, “Vein.”
Dr. Shumway took the vein he was handed, cut it for the right length, and performed a three-vessel bypass.
Once he completed this job, it was time to get the patient off the bypass machine and restart his heart. The doctor called for potassium and medication and now the paddles, and he was telling us all to stand clear so we didn’t get electrocuted. He placed the paddles directly onto the patient’s heart.
Boom!
Buh-bum. Buh-bum. Buh-bum.
The banker’s heart was going again.
Dr. Shumway had no change in expression.
“Next case,” he mumbled, and left the room.
Alex unfroze. He would go on to become one of the great heart surgeons in the Deep South.
One week later, the doors to Stanford University Hospital whooshed open and a banker – a leg vein now running from his proximal coronary artery to the base of his heart – walked out into the California sunshine.
My very first operation as a resident.
What’s important in life?
To help people not die. That’s one. But you see people die all the time. Old people, young people. Teenagers, pregnant women. There’s no justice to it, no value system, no right, no wrong. They just die. Bad genes, bad luck. You don’t know what to make of it. You’ve seen it happen like this before, in bulk, and then it involved children, lots of them. Do you get used to it? Does anyone? You were raised Anglican, went to Sunday school; throughout boarding school and college you attended church. You’re not sure what you believe. You’ve read the Bible, the Torah, the Koran, the Bhagavad Gita.
People keep dying.
When you see death day after day, you have to do something positive with it. You help people, yes. Well, that’s good. Keep them from dying too soon. Keep them from living with sickness, from living too unhappily. Good.
But what about for yourself? How do you keep from losing it? How do you keep despondency at bay?
You cultivate a healthy appreciation that every day is special. You appreciate that every day may also be your last.
Welcome to the life of a medical resident, cardiac rotation.
Tory, my girlfriend of five years and in her first year of law school at New York University, said she wanted to get married.
I told her I wasn’t ready.
We broke up.
A year later, she would marry someone else.
Nasty Surgeons, Not Enough Sleep, and Other Myths
At Stanford, as at all surgical residency programs, my plastic surgery rotation consisted almost entirely of work and training in reconstructive, not cosmetic, surgery – hand surgery, head and neck reconstruction, postorthopedic-surgery reconstruction to cover exposed implants. Later, I would need to learn the nuances of cosmetic surgery, of course; I couldn’t expect to really understand spatial dimensions, 3-D relationships, skin thicknesses, and anatomical planes until I’d done more face-lifts than I could count.
But I was in my surgical residency, first and last, to learn what it takes simply to be a good surgeon.
Watching and working with great surgeons, I was learning what their common traits were. They were decisive. (Outside the OR, surgeons are often reflective and even filled with self-doubt; in the OR, they’re decisive.) When a problem arose, there was no dithering. Before you blinked, they were already working toward a solution, or taking a different approach. Their hands were always moving. They knew the ins and outs of the procedures and they were technically skilled, of course, but, of equal importance, they had a suppleness and resourcefulness of mind to take a different course. Like great chess players, the most skilled ones had plotted their actions several moves in advance. Over the years, watching them at Michigan, Duke, Stanford, and several New York hospitals (among others), I have always marveled at and appreciated the great ones.
You could say they’re hyperconfident and sure of themselves. Cocky and arrogant, even. You almost can’t help being that way. First, surgery tends to attract the most alpha, testosterone-fueled of an already alpha group, doctors. (Of the twenty-four plastic surgical residents in my six-year program at Stanford, three were women. I don’t know how much of the scarcity of female surgeons is systemic bias, how much is self-selection, how much is other factors. ) Second, what we do is pretty mind-blowing, if you think about it. Every once in a while, while operating, I’ll catch myself thinking about how odd, how unnatural, it is to do what I do: I’m taking a knife to someone, she’s bleeding, there’s her fat, there’s her muscle…In my first weeks during my plastic or otolaryngology surgery rotations at Stanford, when I might be operating on patients with cancers, my momentary, out-of-body ruminations were even more sobering: His life is in my hands.… If I screw up, he could be seriously injured … or I could kill him.…It’s a weird, unique, complicated, ultimate thing we surgeons do.
Confidence entered me sometime after I’d done a thousand of a given procedure. To me, confidence simply means an awareness that I’ve put in the work, that I know my abilities and limitations, that I appreciate medicine is both a science and an art, that I’ve done all I reasonably can to protect the patient and myself against the unpredictable.
I have also watched surgeons who shouldn’t be surgeons. They delay. They are unprepared. Often, they’re the cockiest of all. (Unlike the rest of us, they’re not constantly terrified that something might go wrong.) When you think you know everything, you don’t train as hard. Or you get sloppy. I know of a self-righteous, quick-to-pontificate chief of surgery who felt he didn’t need to be in the OR in the moments before performing a hernia repair – a common, generally uncomplicated operation. Instead he was drinking coffee in his office while his thirteen-year-old