Although several anesthesiologists had given it their best effort, even one nurse anesthetist who was reputedly the best in the department at placing spinal needles, no one was able to do it, and eventually they decided to use general anesthesia. Once that decision had been made and the patient put to sleep, the operation was able to commence.
The patient’s size made Mitt feel that he’d truly been needed to provide exposure to the veins, particularly in the woman’s groin. The attending physician’s name was Dr. Winona Benally — a particularly talkative and diminutive woman who needed a stool like the scrub nurse. During the forty-five minutes the actual operation took, Mitt learned more about vein stripping than he ever realized there was to learn, meaning from his perspective the operation was probably the best so far of his Bellevue career. The only blip in the procedure was another strange forceps incident. Just when Dr. Benally was about to tie off the saphenous vein on the right side, a pair of forceps fell directly into the incision that Mitt and Dr. Singleton were struggling to keep open.
“Hmmm,” Dr. Benally voiced questioningly but calmly. She put down the needle holder she held on the drapes and rescued the forceps. Holding them up, she turned to the scrub nurse. “Where did this come from?” she asked in a pleasant but obviously confused tone.
The scrub nurse, who’d been busy opening additional suture packets she’d just gotten from the circulating nurse, leaned toward the surgeon, looked at the forceps, and said: “I have no idea.” She took the instrument, examined it more closely, and, with a shrug, returned it to the instrument tray.
Dr. Benally directed her attention across the patient to look at Mitt and Dr. Singleton. “Did either of you see where those forceps came from?”
Dr. Singleton said no. Mitt merely shook his head. He was tempted to describe similar forceps anomalies that had occurred in surgery the day before and the day before that, but he hesitated. It sounded too weird, so weird he wondered if he’d imagined it. Yet, wasn’t this another similar event?
“No matter,” Dr. Benally said with a gesture of indifference. “Let’s get on with this.” She picked up her needle holder and went back to work. About twenty minutes later, the operation was completed. After the drapes had been removed, everyone helped wrap the woman’s legs in Ace bandages while the anesthesiologist began to revive the patient, but a problem quickly developed. The anesthesiologist wasn’t able to wean the patient off the ventilator, seemingly because the patient wasn’t able to adequately breathe on her own, presumably because the weight of the adipose tissue of her breasts and upper chest prevented her from doing so.
The moment Mitt became aware of this situation, he began to feel progressively nervous. Elena Aguilar was his fifth surgical patient, and it now seemed she was having difficulties, certainly not as bad as the others, but worrisome nonetheless. The disturbing question in his mind was whether something bad was going to happen to her. When he asked the anesthesiologist what she thought, he was relieved to hear she fully expected it was not going to be a problem. She thought the patient might have to stay in the PACU a little longer than usual, but otherwise everything would be fine.
“All right, that’s that!” Dr. Goldstein said, breaking into Mitt’s reverie. The surgeon handed off the instruments he’d been using to the scrub nurse and stretched his back after having been bent over doing the lymph node dissection up in the patient’s axilla. “Obviously, we’ve cleaned everything out superbly. Now it will be up to the radiologists and oncologists. One thing I’ve definitely learned in my career is that treating breast cancer is truly a multidisciplinary activity.”
Mitt relaxed the hold he had on the retractor, and Dr. Singleton took it out of his hand. Mitt stretched his own back and then his neck muscles.
“Okay, let’s begin the breast reconstruction!” Dr. Goldstein said as much to himself as to the others. But then he added for their benefit: “The last thing I want for any of my breast cancer patients is for them to suffer needless psychological morbidity.”
Mitt was impressed with the job Dr. Goldstein did reconstituting the breast’s contours with the closure of the flap he’d created for the axillary lymphadenectomy — although he could have done without Goldstein bragging about his year’s fellowship in plastic surgery. At that point and with Dr. Singleton’s encouragement, Mitt was included in placing and tying some of the subcutaneous sutures as well as some of the skin sutures under Dr. Goldstein’s watchful eye.
When the case was done, the drapes removed, and a pressure bandage had been applied, Dr. Goldstein stepped back from the operating table to remove his gown and gloves. “Well done, gentlemen,” he said. “I trust that you two will see to the postop orders and the dictation.”
“Dr. Fuller and I will see to it together,” Dr. Singleton assured him.
“Thank you, everyone,” Dr. Goldstein called while waving goodbye over his shoulder as he pushed out into the hall and disappeared.
To Mitt’s relief, Latonya Walker recovered from her anesthesia quickly. She was even lucid enough to cooperate in moving her from the operating table onto a gurney.
As Mitt walked along the hospital corridor with Dr. Singleton, following Latonya’s gurney to the recovery room, or PACU, he felt better than he had when he’d followed Elena Aguilar. At least Latonya was doing okay and her surgery — despite being significantly longer — had gone smoothly. Yet Mitt still felt nervous, remembering that Bianca Perez’s surgery the previous day had also gone without a hitch. If something truly bad was to befall either of today’s patients, and unfortunately Elena was already knocking on that door, his sense of responsibility was going to skyrocket.
“Your knot tying isn’t bad for it being your first week,” Dr. Singleton said graciously.
“Thank you, but it needs a lot of work,” Mitt responded. He thought the fourth-year resident was just being kind, because from Mitt’s own perspective he’d been all thumbs under the attending’s attentive gaze.
“There’s some knot-tying setups in the simulation lab,” Dr. Singleton said. “It’s good practice for someone just starting out like yourself.”
“That’s a good suggestion,” Mitt said. What he didn’t say was, When the hell am I going to find the time? Then he remembered he was scheduled to be off the following day and realized coming in to utilize the simulation lab might be a good way to spend at least part of the day. He could also do the admissions for his Friday surgeries then.
Once in the PACU, Mitt and Dr. Singleton sat behind the counter of the central desk to use one of the monitors. With the fourth-year resident looking over his shoulder and making suggestions, Mitt wrote out Latonya Walker’s postoperative orders just as he’d done for Elena Aguilar earlier that morning. While they were busy doing that, the PACU nurses went through the admitting procedure for Walker with the help of the anesthesiologist. Mitt had learned that the PACU was organized in a similar fashion to the ICU, with separate nurses for each patient, at least until the patients were stable and ready to be transported back to their hospital rooms.
When the postoperative orders were completed to Dr. Singleton’s satisfaction, Mitt used a recording line to dictate the details of Walker’s operation, again with Dr. Singleton’s guidance.
“Okay,” Dr. Singleton said, standing and stretching once they were done. “We have a good fifteen or twenty minutes before Diego Ortiz’s thyroidectomy, which might turn out to be a relatively long procedure. With that in mind, I recommend you make a pit stop if you are at all inclined.”