A STITCH IN TIME...

My mother has always had this inexplicable fascination for surgeons and their art of healing with a scalpel. So it is not surprising that I often found myself being a victim of her constant banter about what an amazing life I could lead as a surgeon, and she in turn, as the immensely proud mother of a young surgeon. But it never pushed me to like surgery more than I already did.

I vividly remember the very first surgery I observed. I was in my second year of med school. I had never seen the insides of an OR prior to that. I knew much less about the OR dress code and discipline. But that did not dent my enthusiasm even in the slightest of ways. Dressed in bottle green scrubs, we entered the OR bare foot.

It was a little intimidating at first, even though we were merely observors. In front of us, lay a 45 year old lady who was about to lose something that defined her very essence. She was scheduled for a right sided modified radical mastectomy, having been diagnosed with breast carcinoma. The psychological trauma of having her breast cut off, would probably leave her more scarred for life.

With all due respect, my unit chief was a very ordinary surgeon albeit with a fierce temper that could probably kill the patient before cancer could consume her. He began the procedure with an elliptical incision beginning on the inside of the breast. I had never seen so much blood all my life. Blood stained hands, scrubs, floors. It was mortifying. They kept suctioning all the blood and it still wouldn’t stop oozing out. I secretly thought she would bleed to death. The stench of the cautery slowly but mercilessly eating its way through the human tissue was dizzying and wasn’t helping. The surgery trudged on for what seemed like forever but lasted a good 2 hours. At the end of it, she was surely short of one breast, but the cancer? We were not sure. We could only wait and watch. And hope!

As I entered my surgical rotation for the second time in my final year of med school, I had taken a liking for it which rather surprised me. My unit chief was not just an extraordinary surgeon, he was also an extraordinary man. Watching him resect a gangrenous bowel and anastomosing it in the middle of the night was probably one of the best experiences of my lifetime. (Yes, just being a witness to it.) Its easy to fall hopelessly in love with surgery if you ever saw him playing around with vicryl and a needle holder. Deft and precise, he was everything a budding surgeon hoped to ever be. Being bold as a surgeon is the greatest gift that can be bestowed upon one. And he was gifted. In more than one way.   

Internship was an altogether different experience. I learnt slowly, but effectively (hopefully!!) basic surgical skills and techniques. I got plenty of opportunities to learn and practice with minimal adverse consequences.

Yet, the event that changed my mind about surgery came after I finished all my surgical rotations. It was during my brief stint in Anaesthesia. I was posted in the plastic surgery OT. A 55 year old man was posted for creation of an Arteriovenous fistula. He was diagnosed with diabetic nephropathy which meant his uncontrolled sugar levels had started to stunt his kidney functioning. Without dialysis on a regular basis, he would die very soon. People on dialysis undergo a procedure which involves creating an AV fistula called a Cimino fistula. Our body has two separate blood circulation systems – an arterial system (high pressure system) which contains all the good blood and oxygen that fuels the tissues of our body; and a venous system (low pressure system) carrying the bad blood away from the tissues to the heart which in turn gets filtered in the lungs and returns to the arterial system. It’s a simple cycle really. By creating an AV fistula, we are essentially connecting a small artery to a small vein thereby inducing a hyperdynamic circulation in the body.

The patient was made to lie supine and stretch out his right arm to find a vein. He was given a local anaesthetic, parts painted and draped. The plastic surgeon then got down straight to business! He made a small nick in his forearm and carefully dissected out the underlying tissues. His immense experience was testimony to him spotting the vein in no time. It was clamped. He then proceeded to find the artery adjacent to it. It was pulsating and breathing life, and hence hard to miss. It was clamped. Procedure half done. Sounds astonishingly simple doesn’t it? There is no way an amateur could do this procedure without causing some kind of damage to one of the blood vessels, The whole procedure would be totally futile even if it was only one small puncture. All along, he beautifully explained the entire procedure step by step. It was fascinating for an onlooker.

He proceeded to cut the vein and made a tiny nick on one side of the arterial wall without damaging the rest of it. (This was all of course done after clamping the vessels and obtaining a bloodless field) All he had to do was connect  one end of the cut vein to the cut side of the artery by placing sutures anteriorly and posteriorly. He used 7-0 prolene sutures which are visible to the naked eye only if you have perfect vision. Procedure completed. He released all the clamps and just like that, the now conjoint vessels sprang back to life, pulsating and pushing harder than ever. The operating surgeon let me palpate the vessels after stitching back the skin together. The mixing of the bloods had caused the blood flow to become turbulent which I could appreciate as a thrill. On auscultating, I could hear a low rumbling noise like that of a machine. It only meant one thing – it was a job beautifully done!

“The night fissured and stars rained down on me. Queen of the night, I knew love at last.”