Holding the bloody scalpel of a liver transplant

I tried to grasp the tremendous idea of the bloody scalpel in my hands. This very scalpel had been used less than a minute ago by the resident surgeon to make the same scar emblazed across my abdomen on another man.

“Here, hold it, see how it feels.”

My hands were steady as the surgeon’s as my gloved hands took the scalpel where a slow ooze of the blood from the blade made itself down to my fingers. I was captivated by this man’s blood on my hands, lost in an unorthodox mixture of amazement and grotesque in my head. The resident surgeon looked at me with curious eyes, when just a moment ago I was looking at him with the same curiosity to try and understand what was going on behind his, wondering if it would’ve been the same as 2 weeks ago when he would’ve sliced me open.

“So?”

A flurry of stupendous blinks were all I could conjure up. I’ve been awake since 5 a.m. to get to the hospital by 7a.m. to observe everything about a liver transplant. The first surgeon I met was the resident (note: not the resident who handed me the scalpel)  who had admitted to not leaving the hospital for days at a time. Today seemed no exception, as his ruffled hair and barely open eyes were signs of someone who had just woken up from sleeping in some cold corner of this hospital. His eyes widened with shock as he saw me eagerly sitting and waiting in the preparation room. It quickly narrowed into a smile as he connected the dots and remembered that I had been given permission to observe a liver transplant by the head surgeon whilst I was in ICU. (What better time to ask a surgeon a favor?)

After a series of the introductions, I held up both my recently washed hands. A nurse draped a surgeon coat around the front, and prepared two gloves for me. I felt an unreasoned surge of power and could barely hold an urge to initiate the surgery… no, more like murder if I really did start cutting. The patient lay naked in front of me, fresh from having a tube inserted up his penis. I could feel a wince in my loins followed by the origination of momentary pure self-hatred of one body part to another. During the preparation of this patient, I felt connected with him. Everything done to the man formed itself into a phantom pain to my own body. The needle stabs into  the neck, shoving of tubes down the mouth, oranging of the body with iodine and of course the penis tube, all of it all made the same body part tingle.

Then the intern draped blue blankets all over this man’s body except his abdomen. I felt my connection with the man start to break and the surgery becoming what it is, the treatment of a disease or injury by operative procedures, not a reenactment of a personal experience. This time, I was the one holding the scalpel. Ah yes, the scalpel, the resident had a question for me that so far I’ve only blinked to answer.

“Uhhhh……” was how I showed the resident I was an up and coming med student, quick on my feet. The resident laughed at how speechless I was, instructed me to hand the scalpel to a nurse, as he picked up some high frequency vibrating knife that burned the flesh, cutting it with ease.  Smoke from this man filled up the room (I exaggerate) leaving a distinct smell of burnt meat with a hint of human in my nose. From the smoke, a prick rolled into the room, the lead surgeon for this man.

The atmosphere of the room completely changed. The previously joking resident greeted the surgeon with a solemn hello following it with silence. The intern and nurses shifted uncomfortably, with their eyes downcast, not wanting to catch an awkward glance. The surgery clearly belonged to this man, and depending on what he wanted and how he felt, the surgery will follow suit. For the next 7 hours, if he made a joke everyone would laugh, if he told someone to shut the hell up – everyone would, if he felt like a smoke he would leave the room with the patient’s abdomen spread open, if he swore at the particular difficulties of the surgery – everyone agreed, and if he wanted something done – it got done. Before the surgery, I had asked the resident surgeon how long he had been doing surgery for. “Surgery? What I do isn’t surgery, I just stand-by and help.” I get what he means now.

With the surgery in full swing, this man’s abdomen was spread open by mechanical vices on each side revealing everything inside – an anatomical wonder that was so … alive. Everything responded to the surgeon’s incisions with a fresh squirt of blood and even the organs that were left alone made their presence felt, especially the heart that consistently beat upon the surgeon’s hands via the diaphragm. Lost in the inner anatomy of this person, it’s easy to forget there’s anything beyond it – not once did I think about the patient’s face, his expressions of emotions, his personality or his worried family members.

Who would you want doing your surgery? Someone who is completely distanced and mechanically approaches your body, or someone completely attached to you and heartedly deals with the consequence of each cut and the pressure of the possibility at each corner?

While I was dealing with a million thoughts, the intern doctor – whose job did not extend beyond holding things – found the boredom of the job greater than the value of the patient and started dozing off. First to go were his eyes, his blinks becoming longer and longer until his neck joins in and brings his head into a droop. I watched him with fascination, finding watching him with disapproval was followed by a pang of guilt. Every morning, my lectures start at 9, and almost every morning I would sleep a further hour in the comfortable seats of CQ lecture theatre. The stakes may be infinitely higher here, but the principle was essentially the same. Every bit of knowledge would make us better doctors but the repetition can eventually whittle anything mundane which coupled with sleep deprivation sends us to sleep.

“Hey, pull tighter…. I said pull tighter.” The lead surgeon looked up at the lack of tightness, “Fuck, are you serious? Your actually sleeping? Wake up you idiot.” The intern apologized profusely promising his full attention for the rest of the surgery. The rest of the surgery, if simplified, went more or less like this (most of this was explained in English by an observing doctor on a transfer programme to the hospital). Cholecystectomy (removal of the gall bladder, anything -ectomy means to cut/remove), followed by a hepatoduodenal ligament dissection, then after determining where to cut the bile duct with a radioactive marker, the actual cutting of the liver (hepatectomy). Associated arteries / veins and ducts are all sliced then tied up (suture ligitation).

When the liver is ready for removal, the donor plays the waiting game. Across the corridoor from this surgery room, was another room with the recipient being prepared to accept the liver. The recipient’s liver is removed completely, all the blood vessels and ducts prepared, and the great saphenous vein is cut out from the person’s leg to provide extra blood vessel length for connection.

The clock struck 3:47 p.m. when the call came in that both the donor and recipient were ready. It  had taken 8 gruesome hours to reach this point, and the transplant of the liver was about to go underway. After such careful procedures until now, the actual movement of the liver is a comparitively crude and primitive process. No fancy or high tech piece of machinery, just an ice box that the liver is carefully put into. To minimize ischaemic (due to no O2) damage, the movement of the box across surgery room is a somewhat panic striken shuffle across the corridoor.

That shuffle had made a part of me a part of my dad. Looks like I’ll always be there for him now. With a sly smile at everything I had seen today, I fell exhausted in the preparation room into a blissful nap.