One of the must-have textbooks for a young surgical resident is Mastery of Surgery.
It’s a two volume tome detailing the rationale and methods of surgical
technique for pretty much every operation we do. Everything from the old
Halsteadian radical mastectomy to the laparoscopic Heller myotomy is in
that baby. It’s a wonderful book. I still peruse through it the night
before big cases. But I always hated the title when I was a younger
resident. Mastery of surgery. It sounded so typically pompous and
bombastic; what one would expect from staid, formalistic surgical
academia. The word “mastery” nagged at me, hinted at something
overwrought and unattainable. How could one ever think it would be
possible to master all the vagaries and intricacies of general surgery?
But
my understanding of what it meant to master a profession was woefully
inadequate. It isn’t about memorizing the steps to a bunch of
operations. What I didn’t understand was that it was the vagaries and
intricacies themselves that separate a true master from the journeyman.
You give an apprentice a nice piece of wood and first class tools and
the proper instructions, there’s a good chance he’ll be able to pound
out a decent bookcase for you. It will be sturdy and durable and it
won’t draw negative attention to itself. But a master carpenter can take
a bundle of scrap wood and some shabby blunted tools and he’ll create a
work of art, a centerpiece that guests ask about when they enter your
home. Excellence under adverse conditions. A master surgeon is similar
in this regard.
I had the privilege of working with such a master surgeon in Chicago as a resident at Rush University Medical Center. Dr. Alexander Doolas
was in the latter stages of his career when I was there but he was
still one of the busiest surgeons in the hospital. Dr. Doolas is cut
from that old school cloth of pure bad ass, no holds barred, no
nonsense, work all night, take no excuses, knows more than everyone and
isn’t afraid to tell you kind of surgeon that used to rule the roosts at
big academic centers. (Surgery has now evolved into its kinder and
gentler phase of development with work hour reform and the civilizing
influence of more women entering the field.) Dr Doolas is about 5’6″ and
his physique is cut like one of those Bulgarian power lifters. He’s
always tanned and well dressed outside the OR with his hair immaculately
slicked back like Al Pacino in Scent of a Woman.
Merely standing in his presence as an intern was terrifying enough. But
then he’d open his mouth and this alpha-male, heavily-Greek accented
deep baritone would come growling out and you’d literally start dropping
pens and papers and maybe even slightly losing control of your
sphincter mechanism if you’d done something wrong or forgot a crucial
detail. He scared the hell out of me that first year. He was notorious
for calling interns randomly in the middle of the night for updates on
his ICU patients. The page would come in from an outside line and you’d
sprint down to the unit to review the bedside flowsheet before calling
it back. And you couldn’t make numbers up because Dr. Doolas would often
first call the ICU nurse to get the actual answers and compare it with
what you told him. So we all ended up hanging out down in the ICU most
call nights until after midnight, just in case the old man wanted an
update. His big thing was fluids and electrolytes. The man lived for
sodium concentrations and potassium losses in bile and the exact
chloride composition of pancreatic secretions and urine outputs and the
precise balancing of fluid intake versus fluid losses. After Whipples he
put in G-tubes (gastrostomy tube) and decompressive J-tubes
(jejunostomy) and feeding J-tubes and an NG and you needed to know how
much was coming out of each and what it looked and even what it smelled
like. He thought he could smell when there was a pancreatic leak. You’d
see him digging around on a post-op belly with his bare hands sniffing
the end of the drains to determine his next move. Patients with delayed
gastric emptying after a Whipple can often lose a lot of water and
sodium via NG and G-tube decompression. He sometimes liked to replace
those losses not with saline infusions but with the actual fluid itself.
So nurses would have to collect the G-tube and decompressive J-tube
outputs, put it in a plastic bowl on ice and then refeed it via the
feeding J-tube every shift. It was gross but it made sense. It was
perfect actually.
On rounds, it was the Dr. Doolas show. He had this charismatic,
disarming, eccentrically charming bedside manner that patients just ate
up. They loved him. He projected pure confidence and rightness of
action. He could walk into an old man’s room who’d had a left colectomy
and Dr Doolas would pontificate for twenty minutes on how the Persians
invaded Greece unprovoked and how they got their comeuppance, and then
maybe at the end, right before abruptly leaving, tell the patient that
he needed to start eating more potatoes and the patient would nod
enthusuastically, as if the Holy Ghost Himself had paid him a visit. He
also liked to speak in metaphors. I remember this high maintenance
suburban patient who had had a pancreatic resection and she had a
thousand questions for Dr Doolas about what was happening and why he was
doing certain things. You could tell he was getting annoyed. He took
off his glasses (always a sign of something legendary about to happen),
started gnawing on the tip, and he held up his hand and that deep voice
rolled out at her like a surging wave, “Listen! When you get on an
airplane and you’re flying to Milwaukee to see your cousin Angelo, do
you get up out of your seat and go knocking on the pilot’s door and ask
him what that knob is and why that light is flashing and how’s come the
dashboard is beeping like that? Do you? No. You don’t. So you let me fly
this plane.” Some of his metaphors, however, tended to be seemingly ad
libbed and barely coherent. You could ask him why he wanted to restrict a
patient to scrambled eggs without the yolks, red beans, and unbuttered
toast and you were liable to get an answer along the lines of: “Listen.
When you get on the bus and you want to get to Evanston there’s always
an old lady sitting next to you asking if you know where her recipe book
is and meanwhile there might be an elephant at the next stoplight but
you don’t know you so you have to count backwards from 57 by threes
until you get to the second prime number and then it’s like when the
Inuits crossed the Bering Strait and it all becomes obvious. You got
it?” And he’d stare at you like you were the stupidest person on earth,
your mouth agape, wide eyed, not knowing what in the hell to say, and
he’d finally just shake his head and walk away.
In the OR Dr. Doolas was legendary. He was famous for the two hour
Whipple. The 20 minute colectomy. He’d hunch over the table, his giant
bald head inches from the pancreas, headlamp illuminating an orb of
intimate anatomy, and everything he did, every move was filled with
purpose. He didn’t move fast, he just didn’t waste any action. Every
maneuver served the purpose of advancing the operation toward its
logical conclusion. There was no dicking around, no hemming and hawing,
no tentative picking and pawing at tissues. He knew where he was at all
times, where he needed to go, and what was necessary to facillitate that
end. He didn’t let the residents do much unless you were a chief and
then, only if he liked you. But operating with Dr. Doolas was beside the point. It was enough to just watch the man in action. Two cases come to mind.
The first was a lady who had been referred to Dr Doolas from an
outside hospital. The poor lady had been suffering from an
enterocutaneous fistula for over a year. She’d had multiple operations
and she hadn’t been eating and she just seemed broken and defeated.
Green bile leaked from her fistula near the belly button. Scars
criss-crossed her abdomen. She looked gaunt and emaciated. Everyone else
had given up on her. Dr. Doolas reviewed her scans and xrays and put
her on the OR schedule for the next day. Under anesthesia he made a
single incision through the midline scar and it soon became apparent we
were dealing with a frozen abdomen. A patient who has had peritonitis
and multiple operations can develop so much scar tissue that all tissue
planes are obliterated; it’s as if someone has poured cement between the
loops of bowel. There’s no free space. Everything is socked in, frozen
in place. Every move you make is fraught with hazard. It’s easy in these
situations to do more harm than good. It’s a situation that most
surgeons try to avoid and that’s why a lot of them end up ultimately
with surgeons like Dr Doolas. After the initial incision, Dr. Doolas
asked for a hemostat. For the next 60 minutes that’s all he used. I
watched him wield that blunt tip of the hemostat like chisel, chipping
and scraping and carving his way through the scar and granulation tissue
until he had isolated the loop of bowel involved in the fistula and
separated it from the abdominal wall. It was like watching Rodin create a
masterpiece out of a block of granite. In ninety minutes he completed
what would have taken any other surgeon 6-8 hours. The patient went home
in 4 days, happier than she had been in over a year.
The other case was a thin guy who had had an esophagectomy with a gastric pull-up
a number of years ago at an outside institution. He then developed a
stricture at the esophagogastrostomy anastomosis in the neck. A previous
revision had re-strictured. Multiple attempts at balloon dilatation had
failed. Now the man could not swallow even a glass of water. He was
dependent on a feeding jejunostomy tube for nutrition. But he missed
eating. He missed being able to cut up a perfectly cooked filet,
chewing, savoring the juices, the act of swallowing. He wanted to
experience it again. No matter what. Telling him no would have been
entirely reasonable. He was living at home, surviving, getting by. There
was no emergent rationale for further intervention other than the
patient’s consuming desire to eat again. Dr. Doolas was his last hope.
No one else would take the case.
The day of the operation, Dr. Doolas was in one of his happy moods,
razzing everyone, laughing easily, seemingly unperturbed by daunting
task at hand. Any redo surgery is tricky and trying to revise an
anastomosis in the neck for the second time is especially perilous. The
neck is a small, contained space and important nearby structures like
the recurrent laryngeal nerve and the carotid sheath are at risk of
injury. It’s a veritable hornet’s nest of danger. But once again I
watched Dr. Doolas use just a scalpel and a dissecting clamp to carve
through dense scar tissue until, miraculously, the striated meaty fibers
of the proximal esophagus appeared. From there, he worked his way down
to the old anastomosis. Once eveything was dissected out he looked over
at me, eyes glinting, and he tossed his head back and laughed, a deep
hearty laugh, a guttural guffaw, a sonorous, soulful, Count Dracula sort
of laugh from the depths of his being. His hands were momentarily at
rest. The moment lingered. And then he started again. Ten minutes later
he’d resected the stricture and created a widely patent new end to end
anastomosis. The entire case took about 45 minutes. The patient was
eating a hamburger three days later.
A master at work. All I did was run the sucker and tie some knots but
I learned more from those two cases than in any operation where an
attending allowed me to stumble my way through the maneuvers. Just
watching. Seeing things the way Dr. Doolas saw them. The sense of
undauntedness that he brought to a case. The confidence. The experience
and knowledge. The creativity and vision. But I think there was
something else, something you can’t teach, maybe the most important
thing. And it was all contained in that simple baritone laugh, his head
tilted back, eyes slightly closed. It was the laugh of pure joy. For in
that one brief moment the true master of surgery realizes a rare
perfection, the uniqueness of his talents that have allowed him alone to
actualize the healing of a complicated patient. There may not be a
happier feeling in the world for those chosen few. Without that innate
sense of joy, real unadulterated child-like joy, true mastery is
unattainable no matter how many books you read or where you train or how
many Whipples you watch…..
