It was stunning: even someone I considered a moral exemplar had these questions in the face of mortality.
V’s surgery, chemotherapy, and radiation treatments were trying, but a success. He was back at work a year later, just as I was returning to my clinical duties in the hospital. His hair had thinned and whitened, and the spark in his eyes had dulled. During our final weekly chat, he turned to me and said, “You know, today is the first day it all seems worth it. I mean, obviously, I would’ve gone through anything for my kids, but today is the first day that all the suffering seems worth it.”
How little do doctors understand the hells through which we put patients.
—
In my sixth year, I returned to the hospital full-time, my research in V’s lab now relegated to days off and idle moments, such as they were. Most people, even your closest colleagues, don’t quite understand the black hole that is neurosurgical residency. One of my favorite nurses, after sticking around until ten P.M. one night to help us finish a long and difficult case, said to me, “Thank God I have tomorrow off. Do you, too?”
“Um, no.”
“But at least you can come in later or something, right? When do you usually get in?”
“Six A.M.”
“No. Really?”
“Yep.”
“Every day?”
“Every day.”
“Weekends, too?”
“Don’t ask.”
In residency, there’s a saying: The days are long, but the years are short. In neurosurgical residency, the day usually began at six A.M. and lasted until the operating was done, which depended, in part, on how quick you were in the OR.
A resident’s surgical skill is judged by his technique and his speed. You can’t be sloppy, and you can’t be slow. From your first wound closure onward, spend too much time being precise and the scrub tech will announce, “Looks like we’ve got a plastic surgeon on our hands!” Or: “I get your strategy: by the time you finish sewing the top half of the wound, the bottom will have healed on its own! Half the work—very smart!” A chief resident will advise a junior, “Learn to be fast now. You can learn to be good later.” In the OR, everyone’s eyes are always on the clock. For the patient’s sake: How long has he been under anesthesia? During long procedures, nerves can get damaged, muscles can break down, kidneys can fail. For everyone else’s sake: What time are we getting out of here tonight?
I could see that there were two strategies to cutting the time short, perhaps best exemplified by the tortoise and the hare. The hare moves as fast as possible, hands a blur, instruments clattering, falling to the floor; the skin slips open like a curtain, the skull flap is on the tray before the bone dust settles. As a result, the opening might need to be expanded a centimeter here or there because it’s not optimally placed. The tortoise, on the other hand, proceeds deliberately, with no wasted movements, measuring twice, cutting once. No step of the operation needs revisiting; everything moves in a precise, orderly fashion. If the hare makes too many minor missteps and has to keep adjusting, the tortoise wins. If the tortoise spends too much time planning each step, the hare wins.
The funny thing about time in the OR, whether you race frenetically or proceed steadily, is that you have no sense of it passing. If boredom is, as Heidegger argued, the awareness of time passing, then surgery felt like the opposite: the intense focus made the arms of the clock seem arbitrarily placed. Two hours could feel like a minute. Once the final stitch was placed and the wound was dressed, normal time suddenly restarted. You could almost hear an audible whoosh. Then you started wondering: How long until the patient wakes up? How long until the next case is rolled in? And what time will I get home tonight?
It wasn’t until the last case finished that I felt the length of the day, the drag in my step. Those last few administrative tasks before leaving the hospital were like anvils.
Could it wait until tomorrow?
No.
A sigh, and Earth continued to rotate back toward the sun.
—
As a chief resident, nearly all responsibility fell on my shoulders, and the opportunities to succeed—or fail—were greater than ever. The pain of failure had led me to understand that technical excellence was a moral requirement. Good intentions were not enough, not when so much depended on my skills, when the difference between tragedy and triumph was defined by one or two millimeters.
One day, Matthew, the little boy with the brain tumor who had charmed the ward a few years back, was readmitted. His hypothalamus had, in fact, been slightly damaged during the operation to remove his tumor; the adorable eight-year-old was now a twelve-year-old monster. He never stopped eating; he threw violent fits. His mother’s arms were scarred with purple scratches. Eventually Matthew was institutionalized: he had become a demon, summoned by one millimeter of damage. For every surgery, a family and a surgeon decide together that the benefits outweigh the risks, but this was still heartbreaking. No one wanted to think about what Matthew would be like as a three-hundred-pound twenty-year-old.
Another day, I placed an electrode nine centimeters deep in a patient’s brain to treat a Parkinson’s tremor. The target was the subthalamic nucleus, a tiny almond-shaped structure deep in the brain. Different parts of it subserve different functions: movement, cognition, emotion. In the operating room, we turned on the current to assess the tremor. With all our eyes on the patient’s left hand, we agreed the tremor looked better.
Then the patient’s voice, confused, rose above our affirmative murmurs: “I feel…overwhelmingly sad.”
“Current off!” I said.
“Oh, now the feeling is going away,” the patient said.
“Let’s recheck the current and impedance, okay? Okay. Current on…”
“No, everything…it just feels…so sad. Just dark and, and…sad.”
“Electrode out!”
We pulled the electrode out and reinserted it, this time two millimeters to the right. The tremor went away. The patient felt, thankfully, fine.
Once, I was doing a late-night case with one of the neurosurgery attendings, a suboccipital craniectomy for a brain-stem malformation. It’s one of the most elegant surgeries, in perhaps the most difficult part of the body—just getting there is tricky, no matter how experienced you are. But that night, I felt fluid: the instruments were like extensions of my fingers; the skin, muscle, and bone seemed to unzip themselves; and there I was, staring at a yellow, glistening bulge, a mass deep in the brain stem. Suddenly, the attending stopped me.
“Paul, what happens if you cut two millimeters deeper right here?” He pointed.
Neuroanatomy slides whirred through my head.
“Double vision?”