Chapter 16
Wednesday, July 3, 10:45 a.m.
Mitt surreptitiously arched his back and hunched his shoulders to try to help his stiff muscles, which were mildly complaining about his lack of movement over the last hour. He was a second assistant for an attending surgeon named Dr. Abraham Goldstein on his second case of the morning, the breast biopsy of Latonya Walker. The first assistant was Dr. Kevin Singleton, the other fourth-year resident besides Dr. Geraldo Rodriguez. So far the case had progressed perfectly smoothly.
Mitt had done a small amount of retraction assistance in the beginning of the case for the lumpectomy portion, meaning the removal of the questionable tissue from the patient’s breast, but the little help that had been needed had been mostly provided by Dr. Singleton. Later, after Surgical Pathology had reported the biopsy to be positive for grade 1 breast cancer, Mitt was required to provide a bit more help when several sentinel lymph nodes were removed from the woman’s armpit. These nodes had been sent off to Surgical Pathology to see if there was any microscopic evidence of cancer spread. The results would determine just how much more surgery was necessary.
“Dr. Fuller is one of our very new first-year residents,” Dr. Singleton announced to Dr. Goldstein as they waited for the second biopsy results. “Today is his third day.”
Mitt had had a favorable opinion of Dr. Singleton from the moment the man took it upon himself to approach him in the surgical locker room and introduce himself. He was a tall, thin man in his early thirties with a boney face but warm eyes and pleasant demeanor. Andrea had obviously been equally impressed with him. She’d worked with him the first two days just as Mitt had worked with Dr. Rodriguez. Now they’d switched. Andrea was helping Dr. Rodriguez and Mitt was scheduled to be with Dr. Singleton for all three of his cases that day.
“Well! Welcome to Bellevue,” Dr. Goldstein said. He eyed Mitt, who was on the other side of the patient, standing between Dr. Singleton and the anesthesia screen since the operation was on the left breast. “You must have done rather well in medical school. It’s not easy getting accepted into our program.”
“I did okay,” Mitt admitted vaguely when it became obvious that Dr. Goldstein was waiting for a reply even though he’d not specifically asked a question.
“I’m sure you did more than okay,” Dr. Goldstein added with a knowing nod. “I did my residency here, as you might have guessed, and I was in the top ten percent in my class. I had to be. Maybe it was the top five percent. I don’t remember exactly.”
Mitt nodded in return, as he didn’t know how else to respond. He was getting the impression that practicing surgeons, at least the male attending surgeons at Bellevue Hospital, were on the positive side of the narcissistic spectrum.
“What do you know about oncological breast surgery?” Dr. Goldstein asked.
“Not a lot,” Mitt admitted. He’d had several lectures on breast surgery in his third-year surgery course and had done well on the final exam, so he wasn’t completely devoid of resources, but he’d also learned in medical school that it was far safer to encourage a lecture than try to answer questions when dealing with an attending.
“Do you know who is considered the father of breast surgery for cancer? I’ll give you a hint: It was someone who operated here at Bellevue.”
Mitt was tempted to say Dr. Otto Fuller because that was what he’d been told by his father, but he knew that history reserved the credit for Dr. William Halsted, whose life was significantly more colorful than Mitt’s ancestor’s, especially after Halsted’s very public move from Bellevue to Johns Hopkins, where he became one of the four founding fathers of the medical school and hospital.
“Was it Dr. Halsted?” Mitt said, careful to put his answer in the form of a question. When that was done properly, it, too, invariably stimulated a lecture rather than another question that you might not be able to answer.
“You got that right,” Dr. Goldstein said. And true to form he added: “And I’ll tell you what else he advocated. First of all, he insisted on strict antisepsis similar to what we adhere to in this day and age. Second, he encouraged very delicate handling of tissue just like we’ve been doing today. And third, he urged careful hemostasis, which we’ve also done.”
Mitt was tempted to ask Dr. Goldstein if he’d ever heard of Dr. Otto Fuller, but he was reluctant for obvious reasons. Luckily, Mitt didn’t have to wrestle with the urge very long. At that exact moment, the circulating nurse reappeared to say that one of the sentinel lymph nodes was positive.
“Okay, team, let’s go to work!” Dr. Goldstein ordered. “But before we do, I have one more question for our first-year resident. Does finding cancer in a sentinel node mean we need to do a Halsted radical mastectomy?”
Mitt struggled to think of a way to answer the final question with a question, but nothing came to mind. Fortunately, he did remember the lectures. “I believe nowadays we can get the same prognosis and a significantly better cosmetic result with less surgery.”
“Right on!” Dr. Goldstein said, flashing Mitt a quick thumbs-up. “I’m getting the impression you were indeed high in your class, similar to me. As for this current operation, we’ll be doing a rather extensive lymphatic dissection, but we aren’t going to remove any pectoralis muscles, so the result will be far less disfiguring. In fact, it will be damn good, if I say so myself.” Then, turning to the scrub nurse, he said: “Scalpel, please!”
From that point on, Mitt did do a significant amount of retracting as Dr. Goldstein created a large skin flap and proceeded with the lymphatic dissection on the left chest wall and up in the axilla. The surgeon also concentrated on what he was doing, which ended his mild efforts at teaching, if that was what it had been. Mitt was uncertain.
After fifteen or twenty minutes had passed, Mitt began to wonder why Dr. Singleton was even there since, as a fourth-year resident, he was almost finished with his training, and currently he wasn’t doing much beyond anticipating Dr. Goldstein’s actions and helping when he could. The only conclusion that occurred to Mitt was that perhaps Dr. Singleton, like Dr. Rodriguez for the first two days, was there really for his benefit, to make sure his experience during the first week of surgery was as it should be. It made sense from a pedagogical standpoint. The problem with that plan, if it was the plan, was that Mitt’s patients hadn’t been chosen very well, with all four so far turning out to be clinical disasters.
After another ten minutes of the tedious lymphatic dissection and silence in the operating room, where the only noise was the metronomic sound of the respirator, Mitt’s general fatigue began to weigh him down. Seven hours of sleep marred by a recurring restless nightmare had not been nearly as rejuvenating as he’d hoped. Multiple alterations of his posture and tensing his spinal muscles helped, but only for short bursts of time. The very last thing he wanted to do on his third day of surgery was fall asleep and then jerk when he awakened, which had happened to him during first-year anatomy lab after staying up the night prior studying.
To keep himself awake, Mitt replayed in his mind his first case that morning, the vein stripping on Elena Aguilar. In contrast to all the other surgeries that Mitt had witnessed so far at Bellevue, Elena’s surgery itself went relatively smoothly despite her close-to-four-hundred-pound body, which presented a care challenge in getting her from the gurney onto the operating table. The challenge she presented to anesthesia had been another story.
Initially Elena’s case had been scheduled to be done under spinal with the thinking that it would be safer than general anesthesia, but getting the spinal in place turned out to be nearly impossible. Since Mitt had never done a spinal tap, he couldn’t really appreciate the problems the patient presented besides watching the difficulty of getting her positioned on her side on the narrow operating table.