The patient I couldn’t heal

As a surgeon, I take pride in my surgical work. But even the most careful doctors have painful lessons to learn

Topics: Medicine, Life stories, hospitals, Surgery, Doctors,

The patient I couldn't heal (Credit: iStockphoto/Savany)

I take pride in closing surgical incisions. After a cold blade opens the skin and the internal work is done, the only thing the patient sees, or knows, is their incision. Maintaining symmetry, I use the finest threads and the gentlest instruments in an attempt to restore what once was. Some surgical residents leave the wound dressing to the operating room nurses; I personally dress the wound to reassure the patient that his tissues were handled with the utmost respect. For me, it is the last step of any operation.

But as I closed Mr. H’s wound, others in the room looked at me as if I were crazy. After eight hours of surgery, why would I be so careful with something as trivial as the wound closure? The anesthesiologist became impatient, and the medical student stood by awkwardly. Undeterred, I carefully aligned the skin edges and neatly applied the dressing.

A grapefruit-size tumor in Mr. H’s kidney had invaded the spleen and part of his intestine. It was covered with ominous blood vessels, trying to engulf the neighboring organs. The tumor was removed, along with the kidney, spleen and a six-inch segment of intestine. He was going to the intensive care unit with drainage tubes in his chest and abdomen. He needed a breathing tube in his throat while blood was still being poured into his veins.

The incision wrapped halfway around his body. The glistening yellow fat and the beefy red muscle came together layer by layer as we closed the gaping hole. The anesthesiologist peeked over the surgical drapes and insisted that I expedite the closure with staples instead of suture. I grudgingly agreed but still took great care to ensure Mr. H’s skin closure would be perfect. I somehow believed that a nice scar would hide the ruin within.

My attempt at perfection unraveled a few days later. It started with a little redness at the corner of the incision. I probed the wound with a Q-tip and ensured the underlying fascia – the dense fibrous tissue encasing the abdomen – was intact. Removing the Q-tip, I saw the characteristic creamy pus of a wound infection. I could smell it. I removed one staple to allow adequate drainage and packed the small defect with a tiny strip of gauze.

Mr. H’s wife was distraught about her husband’s complicated operation and poor prognosis.  And now his wound was infected. I explained to her that wounds can heal in different ways. When tissues are sewn together side-to-side, the fat joins to fat, muscle to muscle, and skin to skin. But when left open with gauze, the gap fills in with pink granulation tissue from the bottom up. Wounds have a remarkable ability to heal, I told her, but her skepticism was clear. We discussed that overall his recovery was coming along nicely. Only a few days after a big surgery, his remaining kidney was working, he was breathing on his own again, and it seemed that he was ready to come out of the ICU. We were all hoping for a speedy recovery.

But our optimism would quickly fade. The last three months of Mr. H’s life were spent in intensive care; his hospitalization plagued by widespread infection and heart, lung and kidney failure.  Staple by staple, his incision unzipped in a matter of days. The wound looked as if I never closed it – three inches deep, four inches wide and nearly 2 feet long. The fascia was intact, a single layer of tissue keeping the outside from his ravaged insides. We reinserted the breathing tube, put drains into infected pockets of his belly, and administered strong antibiotics. Unable to eat, we gave him nutrition through his veins — this was what he had wanted.

Every morning and every evening I would gently remove a 12-foot strip of gauze from the ruined closure, tenderly wash and inspect the bed of the wound, and repack the defect with a fresh, moistened gauze. Weeks went by, and he regained enough strength to turn on his side to allow me to change the dressing – always nodding approval at my attentiveness. I would ask about his pain, examine him for pressure sores and offer a compassionate smile to his wife. I knew his chances of survival were poor and felt crippled by my inability to do anything about it. He was physically deconditioned and clearly depressed.

Day in and day out I tended to his wound with the same passion with which I closed it. And sure enough that massive incision began to close. My medical school textbook calls it “healing by secondary intention.” Thousands upon thousands of cells at the base of the wound would lay down a matrix of tough collagen fibers and proteins. Microscopic blood vessels would creep in and deliver more healing cells that would break down the matrix and build it back up even stronger. Slowly but surely the rising scaffold would bridge the canyon and close the gap.

It took two and a half months for the final scar to form; there was nothing left to pack. By that time, Mr. H was breathing on his own but was so debilitated he could hardly speak – he didn’t seem to have any desire. We arranged to get him home so he could die peacefully in his bed, surrounded by his family.

A couple weeks later, I received word from his home health nurse that he had died. She ensured me that his family was with him at the very end, and his pain was well controlled. His wound had healed completely.

As I read that email, I reflected back on the time I spent with Mr. H. I thought about my obsession with that wound, my painstaking focus on closing it perfectly. First with staples, and then with gauze. I wondered why, after a long and complicated surgery, I cared so much about bringing the skin edges together so evenly. I knew the prognosis was poor. I could have let his nurses pack the wound.

Mr. H brought me face to face with my own imperfections and limitations; every physician has a patient that does. As a surgeon, I realized there are some patients we just cannot save. As a resident, my role in making management decisions in Mr. H’s care and taking out his tumor was limited. But whether removing a large tumor, changing wound dressings, or laying a hand on a dying man’s shoulder, we do what we can do to the highest degree. Yes, wounds certainly do have a remarkable ability to heal.

Alan Kaplan, M.D., is a resident in Urology at UCLA.

More Related Stories

Featured Slide Shows

  • Share on Twitter
  • Share on Facebook
  • 1 of 11
  • Close
  • Fullscreen
  • Thumbnails

    Ten spectacular graphic novels from 2014

    Beautiful Darkness by Fabien Vehlmann & Kerascoët
    Kerascoët's lovely, delicate pen-and-watercolor art -- all intricate botanicals, big eyes and flowing hair -- gives this fairy story a deceptively pretty finish. You find out quickly, however, that these are the heartless and heedless fairies of folk legend, not the sentimental sprites beloved by the Victorians and Disney fans. A host of tiny hominid creatures must learn to survive in the forest after fleeing their former home -- a little girl who lies dead in the woods. The main character, Aurora, tries to organize the group into a community, but most of her cohort is too capricious, lazy and selfish to participate for long. There's no real moral to this story, which is refreshing in itself, beyond the perpetual lessons that life is hard and you have to be careful whom you trust. Never has ugly truth been given a prettier face.

    Ten spectacular graphic novels from 2014

    Climate Changed: A Personal Journey Through the Science by Philippe Squarzoni
    Squarzoni is a French cartoonist who makes nonfiction graphic novels about contemporary issues and politics. While finishing up a book about France under Jacques Chirac, he realized that when it came to environmental policy, he didn't know what he was talking about. "Climate Changed" is the result of his efforts to understand what has been happening to the planet, a striking combination of memoir and data that ruminates on a notoriously elusive, difficult and even imponderable subject. Panels of talking heads dispensing information (or Squarzoni discussing the issues with his partner) are juxtaposed with detailed and meticulous yet lyrical scenes from the author's childhood, the countryside where he takes a holiday and a visit to New York. He uses his own unreachable past as a way to grasp the imminent transformation of the Earth. The result is both enlightening and unexpectedly moving.

    Ten spectacular graphic novels from 2014

    Here by Richard McGuire
    A six-page version of this innovative work by a regular contributor to the New Yorker first appeared in RAW magazine 25 years ago. Each two-page spread depicts a single place, sometimes occupied by a corner of a room, over the course of 4 billion years. The oldest image is a blur of pink and purple gases; others depict hazmat-suited explorers from 300 years in the future. Inset images show the changing decor and inhabitants of the house throughout its existence: family photos, quarrels, kids in Halloween costumes, a woman reading a book, a cat walking across the floor. The cumulative effect is serene and ravishing, an intimation of the immensity of time and the wonder embodied in the humblest things.

    Ten spectacular graphic novels from 2014

    Kill My Mother by Jules Feiffer
    The legendary Pulitzer Prize-winning cartoonist delivers his debut graphic novel at 85, a deliriously over-the-top blend of classic movie noir and melodrama that roams from chiaroscuro Bay City to Hollywood to a USO gig in the Pacific theater of World War II. There's a burnt-out drunk of a private eye, but the story is soon commandeered by a multigenerational collection of ferocious women, including a mysterious chanteuse who never speaks, a radio comedy writer who makes a childhood friend the butt of a hit series and a ruthless dame intent on making her whiny coward of a husband into a star. There are disguises, musical numbers and plenty of gunfights, but the drawing is the main attraction. Nobody convey's bodies in motion more thrillingly than Feiffer, whether they're dancing, running or duking it out. The kid has promise.

    Ten spectacular graphic novels from 2014

    The Motherless Oven by Rob Davis
    This is a weird one, but in the nervy surreal way that word-playful novels like "A Clockwork Orange" or "Ulysses" are weird. The main character, a teenage schoolboy named Scarper Lee, lives in a world where it rains knives and people make their own parents, contraptions that can be anything from a tiny figurine stashable in a pocket to biomorphic boiler-like entities that seem to have escaped from Dr. Seuss' nightmares. Their homes are crammed with gadgets they call gods and instead of TV they watch a hulu-hoop-size wheel of repeating images that changes with the day of the week. They also know their own "death day," and Scarper's is coming up fast. Maybe that's why he runs off with the new girl at school, a real troublemaker, and the obscurely dysfunctional Castro, whose mother is a cageful of talking parakeets. A solid towline of teenage angst holds this manically inventive vision together, and proves that some graphic novels can rival the text-only kind at their own game.

    Ten spectacular graphic novels from 2014

    NOBROW 9: It's Oh So Quiet
    For each issue, the anthology magazine put out by this adventurous U.K.-based publisher of independent graphic design, illustration and comics gives 45 artists a four-color palette and a theme. In the ninth issue, the theme is silence, and the results are magnificent and full of surprises. The comics, each told in images only, range from atmospheric to trippy to jokey to melancholy to epic to creepy. But the two-page illustrations are even more powerful, even if it's not always easy to see how they pertain to the overall concept of silence. Well, except perhaps for the fact that so many of them left me utterly dumbstruck with visual delight.

    Ten spectacular graphic novels from 2014

    Over Easy by Mimi Pond
    When Pond was a broke art student in the 1970s, she took a job at a neighborhood breakfast spot in Oakland, a place with good food, splendid coffee and an endlessly entertaining crew of short-order cooks, waitresses, dishwashers and regular customers. This graphic memoir, influenced by the work of Pond's friend, Alison Bechdel, captures the funky ethos of the time, when hippies, punks and disco aficionados mingled in a Bay Area at the height of its eccentricity. The staff of the Imperial Cafe were forever swapping wisecracks and hopping in and out of each other's beds, which makes them more or less like every restaurant team in history. There's an intoxicating esprit de corps to a well-run everyday joint like the Imperial Cafe, and never has the delight in being part of it been more winningly portrayed.

    Ten spectacular graphic novels from 2014

    The Shadow Hero by Gene Luen Yang and Sonny Liew
    You don't have to be a superhero fan to be utterly charmed by Yang and Liew's revival of a little-known character created in the 1940s by the cartoonist Chu Hing. This version of the Green Turtle, however, is rich in characterization, comedy and luscious period detail from the Chinatown of "San Incendio" (a ringer for San Francisco). Hank, son of a mild-mannered grocer, would like to follow in his father's footsteps, but his restless mother (the book's best character and drawn with masterful nuance by Liew) has other ideas after her thrilling encounter with a superhero. Yang's story effortlessly folds pathos into humor without stooping to either slapstick or cheap "darkness." This is that rare tribute that far surpasses the thing it celebrates.

    Ten spectacular graphic novels from 2014

    Shoplifter by Michael Cho
    Corinna Park, former English major, works, unhappily, in a Toronto advertising agency. When the dissatisfaction of the past five years begins to oppress her, she lets off steam by pilfering magazines from a local convenience store. Cho's moody character study is as much about city life as it is about Corinna. He depicts her falling asleep in front of the TV in her condo, brooding on the subway, roaming the crowded streets after a budding romance goes awry. Like a great short story, this is a simple tale of a young woman figuring out how to get her life back, but if feels as if it contains so much of contemporary existence -- its comforts, its loneliness, its self-deceptions -- suspended in wintery amber.

    Ten spectacular graphic novels from 2014

    Through the Woods by Emily Carroll
    This collection of archetypal horror, fairy and ghost stories, all about young girls, comes lushly decked in Carroll's inky black, snowy white and blood-scarlet art. A young bride hears her predecessor's bones singing from under the floorboards, two friends make the mistake of pretending to summon the spirits of the dead, a family of orphaned siblings disappears one by one into the winter nights. Carroll's color-saturated images can be jagged, ornate and gruesome, but she also knows how to chill with absence, shadows and a single staring eye. Literary readers who cherish the work of Kelly Link or the late Angela Carter's collection, "The Bloody Chamber," will adore the violent beauty on these pages.

  • Recent Slide Shows



Comment Preview

Your name will appear as username ( settings | log out )

You may use these HTML tags and attributes: <a href=""> <b> <em> <strong> <i> <blockquote>