This week we present two stories from surgeons who had complications with the knife.
Part 1: A routine procedure with one of the primates in her lab becomes much more complicated when neuroscientist Paula Croxson cuts herself with the scalpel.
Paula is a neuroscientist, science communicator, musician and open water swimmer. She received an M.A. from the University of Cambridge and a M.Sc. and a Ph.D. from the University of Oxford before moving to New York to run a neuroscience lab. She is now Associate Director for Public Programs at Columbia University's Zuckerman Institute. She is also the flautist in alternative rock band Marlowe Grey and nerdy rock band Pavlov’s Dogz. The swimming is apparently for “fun.” She is also a senior producer for The Story Collider.
Part 2: When surgeon Bhuvanesh Singh sees his patient back in the hospital months after what he thought was a successful surgery, he grapples with feelings of failure.
Bhuvanesh is an Attending Surgeon at Memorial Sloan-Kettering Cancer Center. He has cared for over 5000 patients with cancer in his over 20-year career at the center. He is recognized as a leader in his field, having delivered over 500 lectures worldwide. He has helped to refine surgical techniques, contributed to the improvements in cancer staging, and has been involved in research that has dramatically changed the management of cancers of the head and neck region and lung. Not satisfied with available treatment options, Dr. Singh completed a PhD in Medical Molecular Biology to pursue laboratory research. His laboratory work has led to the development of novel anticancer compounds that are currently being optimized for use in the treatment of many different types of cancers. The story Dr. Singh is shared today occurred almost 20 years ago and was a defining moment in his career and life.
Part 1: Paula Croxson
I never really liked surgery days. I’m good at it. I’m very good at it. I spent years of long, long days being taught, observing, practicing, being critiqued and honing my skills, so I know I’m good at it. But something could always go wrong. I’m only human.
And so I'd wake up in the morning of surgery day with a dry mouth that wouldn’t go away all day. I couldn’t have any coffee because my hands would shake. Also, I didn’t want to have to stop and pee in the middle of the night’s ten-hour long procedure.
I would make myself eat breakfast, though, because I needed to be alert and strong and not feel dizzy. So I would make sure that I had my little routine to steel myself for the day.
I set the timer for five minutes. I hit my knee into the button to turn on the water and run warm water over my hands. I pull open this sterile metal packet and pull out the scrub brush. It’s covered in a sort of pinky soap that smells like chemicals and I start to scrub in.
I use the bristle side first on the backs of my hands, on the sides of my fingers, and I scrub twenty times on the left side of my left index finger, and then on the back, and then on the right side, and so on covering every surface of my hand twenty times.
On my palms and my fingertips, the sensitive skin, I switch to the sponge side and I scrub the same. I scrub all the way up my arms to my elbows, until my arms are already aching. And I haven't even started the day yet.
Then I rinse my hands off. The timer goes off at the same time. I've got this down to a fine art.
I gown up, put on my gloves and go to help set up.
My colleague is already there chatting about his weekend plans and unpacking instruments. My research assistant is there too. It’s his first day in surgery. He's a little nervous but excited to learn and ready to help.
And there's a monkey on the table, wrapped in blankets and draped with a sterile sheet, his head shaved and swabbed with iodine to make it sterile, so it’s yellow. He looks tiny under there.
I know this monkey. I've worked with him for a couple of years now teaching him a complex memory task, so complex that only primates can really do it, and working toward the goal of finding out something that will help to find a prevention or maybe even a cure for Alzheimer’s disease or dementia.
I care about him because I've spent hours working with him over those years and because he's expensive, but I also just care about him. It’s hard not to form a bond after you spend that much time.
So we need a full team of people to take care of this little guy. My colleague and I will do the surgery. My RA will assist. There's two veterinary technicians just to do the anesthesia, just to make sure that everything is okay. And there's a veterinarian in the room just at the start of surgery just to oversee and make sure that everything goes smoothly.
So we’re ready to go and I start to help unpack the instruments. I open the sterile packs and I tip the instruments onto the steel table covered with a sterile white sheet. Forceps, scissors, hemostat clamps, a scalpel handle, a scalpel blade, which is in one of those metal packets too.
I open it. I hold the scalpel blade properly in a pair of clamps on the handle. I click them together. And then I drive the point of the scalpel straight into the end of my right index finger.
I don't have time to think. I grab my finger and I swing away from the sterile table, because I know that it won’t be sterile if I bleed on it. My blood is full of millions of little pathogens. So instead, I bleed down the wall and on the floor. My finger is gushing blood.
Then I go next door, past the glass partition and through the open door into the prep room because, like any good surgeon, I’m kind of squeamish and I usually pass out when I cut my hands.
My colleague sees me through the open door sitting on the floor, head between my knees next to a red clinical waste trash can and says, “Are you all right?”
I say, “I will be. I just need to sit here until I stop feeling like I’m going to pass out. And then I'll scrub back in and I'll come and help.”
And he says, “Fine. I've got this.”
And the veterinarian says, “You're going to have to scrub that.”
And I say, “I know. I know I’m not sterile anymore, but I just have to sit here first because I feel really faint.”
But she says, “No, you're going to have to scrub that now.”
Through my haze I realize what she means. Some rhesus monkeys have a virus called herpes B virus. It’s a herpes virus, not unlike the herpes viruses that cause cold sores or genital warts in humans. It causes conjunctivitis in monkeys and it can make them feel kind of rundown. Like human herpes viruses, it’s passed through fluid contact. Unlike human herpes viruses, it’s incurable.
But unlike human herpes viruses, if it gets into a human and it crosses the blood-brain barrier into the central nervous system, it can cause viral encephalitis and the person could die.
There's a protocol in place for this. The first part of the protocol involves scrubbing the affected area for fifteen minutes.
So she says to me, “You're going to have to scrub that for fifteen minutes right now.”
And I say, “I don't think I can. I feel really faint.”
And she says, "Do you give me your consent to scrub it for you?”
And somewhere in the back of my brain, a little voice says, “You don’t need this. The scalpel blade was sterile.”
But I’m weak and I’m woozy and she's a veterinarian and she must be right and so I say, “Okay.”
So she takes me gently by the hand and leads me over to the scrub sink and she starts to scrub my hand. She opens one of those brushes and she takes it out. She runs the water and she starts to scrub the tip of my finger and my open wound with the bristle side.
I don't remember the next part, but I have it on good authority that I was screaming at the top of my lungs. And when I come to my senses, I’m doubled over the metal scrub sink with my head on the cool stainless steel and one of the vet techs is holding me up by the shoulders so I don’t collapse onto the floor.
I’m vaguely aware that surgery is still going on behind me with the door open and, oh, God, my RA. It’s his first day! I’m worried about him and I’m deeply embarrassed by the guttural animal sounds that are coming out of my mouth. And I’m pissed because I don't need this. We haven't even touched the monkey yet and the scalpel blade was sterile and this is not necessary.
Thankfully, at this point, the vet has switched to using the sponge side. And I say in a very quiet voice, “Do you think someone could get me a chair?”
So they get me a chair and she scrubs me for another ten minutes. I just kind of sit there at this point and, eventually, she stops. She turns off the water. I wrap my bloody, flayed open fingertip in a paper towel. I strip off my sweat-stained surgical gown and I go to employee health.
There's one person in employee health who knows what to do if someone has had an exposure to herpes B virus. She knows to call the CDC. She knows to take blood from you and get someone to take blood from the monkey and a swab from you and a swab from the monkey and send it all off and give you a two-week course of antivirals just in case something should happen.
I find her and she says, “Why are you here?”
I say, “I don't know,” and I tell her what happened.
And she said, “Yup, you don’t need to be here. There is zero chance that you have herpes B virus,” and she sends me away.
It never even occurs to me to question whether I should go back to surgery. There's no one else to do it. My colleague can’t do it on his own. It’s my RA’s first day. Everyone else is running anesthesia. We’re a small team and everyone has their part.
So I go back to the unit and I try and get in, only I can’t because it’s a fingerprint reader and I've destroyed my fingerprint.
And I hesitate. It’s going to be a long day. I have at least eight more hours of standing without time to pee. I’m going to be in pain, probably going to make it worse by handling metal instruments. I’m probably going to bleed inside my surgical gloves and have to replace them.
But the pain that I’m going to go through is nothing compared with the headache the monkey is going to have when he wakes up. And who else is going to sit with him for hours after surgery to make sure that he's okay?
Somebody has to do this work. And if it has to be somebody, it should be me and it should be my team. It should be people who are so well trained and so attentive and who cares so much that they'll scrub the shit out of the end of someone’s finger just to make sure they don’t get B virus.
So I get security to let me in. I scrub in again and I go to work. Thank you.
Part 2: Bhuvanesh Singh
I’m going to first thank both Maryam and Erin for all the advice they gave. They said don’t have more than one drink. No comment. They said don’t grab the microphone or pull it around. No comment. They said don’t use props. Ed, can I have my first set of slides, please? I’m going to have to use props. I’m sorry.
‘You have to cut to cure.’ That was the mantra. That was the central focus of all of my surgical training. That’s what I was being taught.
When I first met Alice, I had finished four years of medical school, I had finished six years of residency training, and I was deep into a two-and-a-half year fellowship at Memorial Sloan Kettering. So the way that I thought about my role as a surgeon was pretty well established. I knew my job. My job was, of course, to cut to cure. That’s what I was meant to do.
Now, Alice had cancer of the tongue and she was very atypical. First off, she was very young. She was only 36. Most people who have tongue cancer are older and they tend to be smokers and drinkers. Alice, clearly, was not, so it made her different.
There was actually one other thing that had made her different. Alice was pregnant.
It’s going to be tough. I’m sorry.
So as I walked into her room, she was talking to her husband. She was going over the details of everything that he needed to do while she was in the hospital. As I watched her, she was confident. She was focused. She was completely in control of everything that was going on in the room.
So I did what I had done so many times before. I started to take her history. I started to fill out the paperwork that was required to get her ready for surgery. As a fellow, that was my job and that’s what I needed to do.
Of course, as I did this, I kept my interaction professional, surgical, efficient. Let me get this done so we can move on to the really important stuff, which is the actual operation.
Alice, though, she wasn’t having any of that. She wanted much more than this fact-filled surgical interaction. You see, Alice was a real force and I quickly realized I had no choice but to sit and talk with her. There was no other opportunity for me.
So we ended up talking for a while. When we first started talking, all I can think was, “Man, this is so inefficient. I have so much other work to do.”
But as we talked, her guards came down and, as I think back, so did mine.
She told me about her two-year-old son. She told me about her pregnancy and I told her about my family. You see, I was about the same age. I also had a two-year-old son and my wife and I were expecting our second child. So the similarities were obvious and, for those reasons and for many, many more, we were obviously completely connected.
So we kept talking until her husband finally left the room. And when he did, her voice cracked. I looked at her and there was sheer terror in her eyes. She fought back her tears. She said to me that she had to live. She had to live because she had to take care of her son and she had to take care of her unborn child.
This situation was clearly not familiar to her. She was used to being in control. She was trying to hold on. She was trying to stay strong. She was trying not to show her fear so that her husband wouldn’t worry.
That interaction really affected me and, at first, I really didn’t understand why. The one thing I knew at the end of that, though, is that I had to make sure that Alice was going to be okay. At that point, what that meant to me was that I had to make sure that her surgery went perfectly.
The next day, Alice came into the operating room and everyone was drawn to her. Her personality and her situation really broke through. Even the hardest in the room couldn’t help but be drawn in and completely connected to her.
At some point, the room completely became silent. Everybody knew what was at stake. Everybody was doing their part to make sure that Alice was going to be okay and that she did well.
The normal banter in the room wasn’t there. The room felt completely silent. You could hear a pin drop in there.
I was hiding in a corner. I was going over the steps of the operation in my head and Alice saw me. She called out and she asked me to come over. As I did, I desperately tried not to make eye contact with her. Maybe I didn’t want her to see the concern that was in my eyes. Or maybe I didn’t want to see the fear that was in her eyes.
But Alice was a force. I had no choice. I walked over to the table and I held her hand. As I did, from behind my mask, I said, “Alice, don’t worry. Everything is going to be okay. Everything will be okay.”
Those words completely reassured her and I felt her relax. As she went off to sleep, she thanked everyone. We were ready.
Alice needed a complicated five-hour operation. This involved taking out part of her tongue. It involved taking out the lymph nodes in her neck. And as a fellow, my responsibility was to help the attending surgeon and learn about the procedure and the process.
But on that day, instead of assisting, I slowly took over. Nobody stopped me. You see, this was Alice and it was my job to make her better. There wasn’t anyone in the world that was going to do better than me that day.
The surgery that day, it flowed like artwork. The room was absorbed. Everybody was watching the brushstrokes as the instruments were moving across the field. Every structure, even those that we normally don’t even think about, were carefully identified and preserved.
At the end, the cancer was completely removed. All the margins were clear. The surgical field was flawless. And even my typically very harsh and very judgmental attending had to stop and take notice. On that day, I was perfect.
So of course we celebrated the surgical success with Alice and her family. We all felt that a weight had been lifted and a sense of order was somehow restored.
To no one’s surprise, Alice’s recovery went way ahead of schedule. She was eating and speaking normally in two days, she was out of the hospital in four days, and a week later, she flew home with her family and went back to her normal life.
Later, as I thought about what had just happened, I felt completely satisfied. I felt like I had done my job. I had no doubt in my mind that Alice and her family would now be okay. I had cut. And of course now that meant that Alice would be cured. That’s what I expected. In fact, that’s what everyone expected.
A few months pass. I was still a fellow. I was actively involved in my training. Under the heavy workload of the day and the countless surgeries that I was performing, Alice slowly became a distant memory. My experience with her, though, left me with a strong sense that surgery was indeed my primary purpose. I remained focused towards perfecting the precision and the efficiency of using cold steel, the best care for the patients that I was treating.
One day, after a long case in the operating room, I was making rounds on the hospital floor and an older woman came running across the floor. As I watched her, I saw she was hiding something under her coat. When I looked closer, she was hiding a baby under her coat.
Now, the hospital can be a very dangerous place for babies so I ran after her with a sense of urgency. And as I got to the room where she was going in, I had a whole lecture ready for her to say why she was doing this and how dangerous she was. But when I walked in, my eyes were drawn to this gaunt and frail woman sitting in the hospital bed.
She was in obvious pain. She was having trouble breathing. She was gasping for air. Her hair was frazzled and her eyes were barely open, but when she saw me, she perked up and she smiled.
At first, I didn’t recognize her. But when I looked in her eyes, I realized who she was.
I felt my knees buckle. The room started spinning and I had to steady myself. There in the bed was Alice. She was barely recognizable.
The woman that had been running across the floor was her mother and the baby was her six-week-old son that her mother was bringing to be with her.
Alice’s cancer had unfortunately progressed. I'd seen this look before. I knew exactly what it meant. In I saw in Alice’s eyes she also realized what was going on. Alice was dying.
I was in complete shock. I was completely overwhelmed. I remember running out of the room and somehow find my way to a bathroom and I lock the door then I completely broke down. I cried for what felt like hours.
At that moment, I began to replay every step in Alice’s care, every step of her operation. I did everything right. In fact, I did everything perfectly. Why was she here?
When I finally gathered myself, I washed away any evidence I was crying. I put on a brave face. When I got to her room, I took a deep breath and I went in.
Alice was really happy to see me. I just couldn’t figure out why. I was so disappointed in myself so I hid my shame as we talked and she filled me in on what had happened.
She had flown home. Unfortunately, the pathology from the surgery had shown that the cancer had spread to the lymph nodes. Because of this, she had to endure seven weeks of very damaging and debilitating radiation therapy. But despite this aggressive treatment, the cancer had spread to her lungs. At this point I knew that there was absolutely no hope for curing her.
As I sat in her room, I really struggled to control my emotions. Alice, on the other hand, she was as strong as ever. She was completely focused. She told me she had one goal. And she wanted my help to stay alive long enough to reach that goal. She wanted to write letters and make videos so that her sons could read those letters and watch the videos for each of their birthdays until they turned eighteen years old.
What she wanted to do was make sure that her sons knew their mother. She wanted them to appreciate how much she loved them. And even though she wasn’t going to be there, she wanted to make sure that they were somehow taken care of.
Over the next few days, I checked on Alice regularly, every free minute I had. I did everything I could to help her stay alive. She was so, so strong. The levels of her pain were unimaginable but she refused to take any pain medications because she wanted to stay focused and alert enough so that she could write letters and make the videos for her sons.
I often watched her from outside her room. I saw her smiling and joking into the camera. She was putting on a brave face so her sons would see her in a good way. As she shared her feelings and her advice, she looked into the camera as if though she was looking at her boys. I really prayed that her boys would see her eyes that were so full of hope and her smile that was so infectious and not the obvious pain and sorrow that she was desperately, desperately trying to hide.
That time for me with Alice was incredibly challenging. I really began to think I had made a mistake. I felt I had failed and that was difficult for me to overcome. You see, Alice, she somehow knew exactly what I was thinking. And late one night when we were talking, she paused.
She looked up at me. She took a hold of my hand and she told me, “It’s okay. It’s okay.”
She told me how much she appreciated everything I had done for her and especially the time that I had spent with her and how much she valued the care that I had given to her. Almost as if so she could read my mind, she reassured me and she asked me to take care of others like I had taken care of her.
Her words were powerful. They were healing much more so than any scalpel or medicine that I had, that I could give her. At that moment, instead of me taking care of her, she was actually taking care of me. Even at the end, she felt better by making sure that those around her were taken care of, including me.
So through sheer will over the next three days, Alice made all of her videos and completed all of her letters. I don't think you'll ever appreciate how difficult this was for her to do. And when she finished, she was elated, and we all celebrated.
A few hours later, she died. I cried with her family and I cried so many times after that I just lost count.
It’s hard to believe but that was over twenty years ago. It really feels like yesterday. This is actually the first time I've been able to share Alice’s story in public, and I really felt the need to share her story because, you see, Alice helped me appreciate the most important thing about being a doctor. She made me realize that it’s not about precision and cold steel but rather about easing fears. It isn’t about cutting the cure but about caring and using hugs and laughter to heal.
I feel so privileged to do what I do now but, today, I see my role as a surgeon very differently. It’s my job to help people during their most difficult time. It’s my job to try and help them heal. I guess it’s my job to try and do exactly what Alice did for me.