Ars Longa, Vita Brevis

“It’s an honor to be here with you today, Dr. Schilling.”

“We’re sure going to miss you, Dr. Schilling.”

“Don’t be a stranger after you go, Doc.”

Dr. Thomas Schilling found the entourage of well-wishers moving, but now wasn’t the time for socializing.  Nonetheless, his surgical mask could not obscure the smile in his eyes as he said, “There’ll be time for all that later, right now we have a patient to attend to.”

Dr. Schilling had been an attending surgeon for nearly 30 years of his 35-year career here at Mercy Hospital, and in that time had become something of a local legend.  He had performed the first laparoscopic gallbladder removal at the facility, served as Chief of Surgery on 3 separate occasions, and on a day that would effectively secure his reputation here forever, performed an emergency splenectomy on a young man who had ruptured his spleen playing football, and who had very nearly hemorrhaged to death—who happened to be the Governor’s son.  Today’s operation was about as routine as they came, a 32-year-old man diagnosed in the emergency department earlier in the day with acute appendicitis.  He had long since lost count of the number of the little wormlike organs he had removed in his career, but even before beginning, he knew this one would have a special place in his memory.  This was Dr. Thomas Schilling’s final surgical procedure prior to his retirement.

There is a ritual that is performed before every surgery, at least for the past 150 years or so with the adoption of sterile technique.  First came the actual “scrub in”, performed in front of a large basin.  First, the area under the nails was scrubbed with a medicated file.  Then, using antimicrobial soap and a disposable scrub brush, every square inch of skin from the elbows down was meticulously scrubbed, hands higher than elbows, so the dirty water would run down off the elbow rather than re-contaminating the hands.  Then the arms are run under running water, again starting at the hands. The process was supposed to take no less than 3 minutes, and he had done this so many times that it required no conscious thought to meet that target.  After scrubbing, the surgeon goes in the operating room where a nurse waits with a sterile towel for the doctor to dry off.  The nurse then would assist the surgeon with donning their sterile gown, and lastly a pair of sterile gloves would be applied.  Dr. Schilling found the precise choreography of the prep time calming, a time to go over the procedure in his mind one more time before committing scalpel to skin.  He smiled to himself as he remembered his own mentor so many years ago asking him what the most important procedure was prior to beginning any surgery.  After several of his responses were met with a “nope” and an amused look, his instructor finally said, “Peeing.  It’s a bad look if you have to break scrub halfway through an operation to take a leak.”

The pregame festivities completed, Dr. Schilling greeted the surgical team, which this day included Dr. Michael Fields, first year surgical intern.  Actually, first month surgical intern, as the new trainees had just arrived a couple weeks ago on July 1.  Dr. Fields would mainly be observing, as the senior surgeon would demonstrate the operation, pointing out key technical points along the way.  Some teaching surgeons were legendary for their brutal beratement of physicians-in-training.  Dr. Schilling, having borne the brunt of all too many ass-chewings as a junior resident, made a point of making his point without going out of his way to humiliate his young charges.

“All right team, let’s do our time-out checklist.”

Time-out was another operating room ritual, one with the very specific purpose of patient safety.  During time out, the patient’s identity was confirmed in front of the entire surgical team, the planned procedure was announced, including which side of the body if pertinent, medication allergies were reviewed, consent for surgery was confirmed, and the anesthesia plan confirmed.

Time out having been completed successfully, the team assembled around the patient, who was covered in a blue sterile drape save for a smallish square of exposed skin where the incision was to be made.  Dr. Schilling took these last moments to take a deep breath and clear his thoughts.  Even for such a routine procedure as an appendectomy, surgery required focus.  He closed his eyes, focusing on the rhythmic BEEP, BEEP of the heart monitor, the slower rhythm of the ventilator supporting the patient’s breathing during anesthesia, the faint hum of the overhead lighting. 

“All right, if everyone is ready, shall we begin?  Number 10 blade, please.”

The scrub nurse, anticipating the order, already had the scalpel at the ready and passed it to Dr. Schilling, who proceeded to make the opening incision, pointing out the anatomic landmarks to the intern Dr. Fields as he did so.

With the precision of a finely tuned Swiss watch, Dr. Schilling proceeded to dissect the tissue down to the target in the right lower abdominal quadrant.  The appendix, normally about 4 inches long and a quarter inch in diameter when healthy, was swollen to about half again those dimensions.  Carefully visualizing the entire organ, the surgeon was relieved to find no evidence of rupture.  The patient should have a rapid and complete recovery.

As he began the process of removing the diseased appendix, Dr. Schilling again turned his attention to Dr. Fields.  “So, Dr. Fields, what can you tell me about the patient?”

The young intern dutifully recited the patient’s medical history as he had been taught in medical school: “Mr. Tyler Jameson is a 32-year-old male who presented to the hospital earlier today with the chief complaint of right lower abdominal pain, starting several hours prior to presentation, without radiation, associated with nausea and 2 episodes of vomiting…”

“Yes, that’s all true, what I was asking was, what do you know about Mr. Jameson, the human being?  What does he do for a living?  Does he have children, family in the area?  Any hobbies?”

Dr. Fields stumbled for a moment, not expecting this line of questioning.  “Well, he’s married, I know that because I met his wife in his room.  I think I remember him saying he has to travel a lot, but I’m not certain of his occupation or any hobbies.”  

Dr. Fields’ gaze met that of his teacher, but instead of the disapproving scorn he expected, he saw sympathy, perhaps tinged with a little disappointment.  “Michael, I know I caught you off guard there, but listen, I don’t play ‘gotcha’ games with my residents.  Mr. Jameson here does have a wife, you’re right, but he also has a young daughter at home, a daughter with severe spina bifida who requires a lot of hands on care.  Mr. Jameson won’t be able to help out with his daughter the way he usually does for at least a week or so, and they are new to town and don’t have a lot of social support.  So you and I are going to go speak with social services when we’re done here and see what we can do to get some help in that house for his daughter and wife.  But it’s more than that.  Look at this day from Mr. Jameson’s perspective.  He woke up this morning with a rip roaring bellyache but he had no idea he’d finish the day in a hospital, let alone out cold on an operating table.  Yet here he is, allowing a man he had never met before today to put him on a table, render him unconscious, cut him open and start fussing with his innards.  You and I, we train for this, it’s our job and it becomes routine.  But when you think about it, Michael, the trust these people bestow upon us, it’s simply awesome.  Not like “cool, awesome,” but the original meaning of the word.  To inspire awe.  Every day, you’re going to be taking care of someone’s child, many times also someone’s spouse, or parent, or sibling.  What we do here impacts more than just the person on the table.  If you take nothing else away from your time with me today, Michael, take this:  This job, this profession, is a privilege like no other.  You can do more good in one day here than many people can hope to in a month.  You can also do more harm than many people will do in a lifetime.  Know your patients.  Be with them.  They will repay you in ways that money can’t.”

The procedure was winding down now.  The diseased organ had been removed and sent to the pathologist for further testing.  All that remained was to close the incision, the patient would be taken to the recovery room, and surgeon and intern would go out to the waiting family and thankfully report that all had gone well.  All in all, a completely routine operation, thought Dr. Schilling, but still a privilege to have been of service.