Tuesday, March 30, 2010

The Surgeon

There lies a deep gash, a wound so wet and fomenting in its essence that there are few brave and willing souls that would undertake closure. It lies weeping incessantly of the blood borne of its hard ambitions, wanton desires and gaping secrets. The flesh torn, the sinews disrupted, the nerves severed and the blood vessels ripped and contracted into a coagulated nondescript mass. This is the wound of the tormented souls. It aches of fervent fever, hot, restless and unmanageable. Eyes wander over it, feeling the grate and fret of the soul underneath.

They, the public, shield their eyes, or walk as if it does not exist, they wander around attracted by the invisible pull but repelled by its presence. Some offer words of comfort and then make hasty exits while others know not what to say. They bring self-purging alms to wash off the unruly and distasteful feeling planted by the visual of so heinous a sight. It is humanity in all it glory. Humanity is “feeling” the pain or the fever or the discomfort or the “whatever” that it cannot express but shivers to shake it off. But there they are all bundled together in the warm blanket of giving nothing but seeming to do so. Comfortable in the self-satisfied sense of having done some “good” for those less fortunate, all the while swimming in the delusion of philanthropy. These are never the ones to untie the bandage and care for the wound, only to view it at a distance and promulgate some arbitrary mechanism to wash the self-loathing flotsam.

It is always the one with the express desire to heal, to protect, to make things better, who propels into this ghastly drama. The wound washing, cleaning, ridding of all the infective elements that appear benignly innocent of action, yet are the destructive force under wraps waiting to pounce and destroy any attempts at cure, and then closing the wound to allow a healing to begin. The unsung hero walks in and then out of the drama, not meaning to stay one moment longer than necessary once comforted by the knowledge of his action and the patient’s foot on the first rung of the ladder towards recovery.

Healing is a self-sustaining ritual, mostly, yet it needs a catalyst, a friend, a real physician purged of all self importance and imbued with the desire to help and heal and not to become the cast member on the stage. Life is a stage with actors that don’t feel and directors that don’t understand and stagehands that live only for the staged moment. It is only the producer of the drama with the dream and desire to tickle the nerve strings of the audience. His is the lonely life that conquers all the inertia and fuels the life into the act. He determines the players that would make the act a success, as does the healer. For in him the success of the act is personal, not for glory but the artistic desire of creation and preservation. He is the grand puppeteer and not from the rubbernecking crowd that stalls the highway of progress but one of the few that grinds and frets through the details of work. He is much maligned but never aligns himself to any group or cause. He is the penultimate unreasonable man. Success to him is not at any cost but at some cost to self.

         Scanning Micrograph of Red, platelet and white cell

And so here he was again catapulted into the front and center of the harsh reality, the theater of life’s drama, as life oozed slowly from the darkened red exposed flesh of the wound. The spectrum of colors changed from bright to dark to black. The color itself was bleaching the life out of the flesh and leaving it to the remoteness of the dark shadow of the black caped Reaper. The patient lay drenched in the stupor of the life’s protective humors, his leg was swollen with the vitiating force of the body defenses. His left leg was half the size; He was barely in the realm of reality, teetering on the edge of here and there.

              Antoni van Leeuwenhoek who first used a microscope

 The nurses worked hard at dressing and bandaging the wound and yet it gaped and laughed back with impunity.

                  A Macrophage sensing the bacterium

Several of the white coats clustered around some leaving while others joining through the wee hours of the day, looking, learning and “feeling” the twinge of “it could be them laying there,” and then quickly shrugging the vulnerability and walking away to drown the thoughts that laid bare their fears, talking to themselves at the options that diminished steadily. Some gave suggestions to the Resident in-charge while others decided on a course of different antibiotics and some stood baffled at this runaway train of dermal hostility.

                A White Cell interacting with a bacterium

The white cells meanwhile continued to pour into the deepening gash of bacterial warriors, claiming more and more territory. Each barrier created by the white cells was breached by the ugly hard and vindictive bacterial beasts who also fought and clung for their own survival. The battle waging in and outside of that tortured skin was based on survival. 

                      A Polymorphonuclear  (PMN) Cell

The White cells (polymorphonuclear cells, macrophages) were fighting for the survival of the man, the human and within that representation his race as much as their own. 

                                   A Monocyte

They laid themselves down in trench after trench for the good of the human as the armed forces do for the better of the country. The lymphocytes akin to intelligence officers lay isolated and in a partially degenerated state confused by the overwhelming onslaught of the enemy forces- the bacteria. 

          Neutrophils (PMNs) and bacteria in the spinal fluid

This was representation of the crumbling immuno-surveillance of the body.

Meanwhile the foraging brutally self-serving bacterial beasts like the terrorist band of Genghis Khan, Attila the Hun and Hitler kept claiming more and  more territory for their own. The battle of the selves raged and the gash of charred destruction continued to grow.

                         A Bacterial Cell

The doctor, a surgeon by years of practice stood over the dressing and then after performing the ritual of disinfection he approached the wound, delicately removing the bandages. Enough with the antibiotics, this wound was recalcitrant in its anger. He would have to remove the offending tissue to allow the healing to have a shot at winning the battle. He slowly and with timed precision almost in perfect harmony snipped away at the bad tissue. His precise and deliberate motion was sometimes reflecting on the progress made and then contemplating the work ahead. There was no stealth, nor hurry in his motion. He asked the nurse for instruments and used them to their full potential. The angry wound relented as it reluctantly gave up the gangrenous tissue. 

A Macrophage opsonizing and phagocytosing the bacteria

Antigen Processing by the Immature T Cell and maturation with both cytotoxic and helper T cells

When after four and one-half hours of meticulous endeavor he finished with beads of sweat dripping from his aged brow, the raw edges glistened with color and resolve once again. The deliberation of his action allowed even those observing in the operating room to hold their breath in respectful admiration. Never a loud word or an inadvertent movement followed from the doctor’s efficient activity. It was a symphonic accord in words and deed.  His was an unblemished work of decency, of desire and of humanity. When all others had lost their way, he had not. He was like the spider slow and persistent in his action making the beautiful dew drenched web. Every motion of exactness and every action imbued with self-reliance, finishing his act with perfection.

                  Phagocytosis by the Macrophage

Hours later he sat with sweat dripping from the physical and mental nature of the recent duress. “Tough, that one. I knew if there was enough tissue, I could close the wound and debreed all of the gangrenous crud.”
“You can say that again. But you did that well.”
“I could have done I better. If I had…” he drifted into his mind of how he could have saved time for the patient under the anesthesia and not spent time scrubbing the bad tissue which ultimately had to be sacrificed anyway.
“If not for the completeness of the job this leg would have taken a life!”
“I know but one must always consider learning from the past.” He was in his sixties and moving towards retirement but the wealth of experience and knowledge that others could learn from him would be lost.
“You still have it, you know?”
“Not for long.”
“Don’t tell me you are going on that retirement bus again?”
“It might just be time for that.”
“Not yet. There are so many young ones who can learn from you.”
“I doubt that.”
“I heard a couple of young ones talking in the locker room, the other day and they were criticizing that scrubbing with me was extremely time-consuming for them.”
“There will always be those. But most respect you.”
“Really! How about the admin protesting that I occupy the OR more than others doing the same kind of surgery?”
“Your results speak for themselves. Never an infection, never a bad outcome, never anything deleterious, always a perfection”
“Unfortunately the young are in a hurry and the business side looks only at time with an eye to the almighty dollar. I thank you for your words but my time has come and gone.”
Just about then with his eyes downcast into a contemplation of his future, the sound of a single person’s applause broke the silence. It was joined by another and then another and pretty soon the Staff Office was deluged with the thunderous ovation from his young and old colleagues. Unbeknownst to him they had seen the magic in his hands, the will of his mind and the benefaction in his soul. They had seen him for who he was and what he had accomplished. They had recognized the meaning of his downcast gaze, the virtue of his selflessness and the helpfulness in his teachings. In their minds he had earned this applause.

He lives in a modest home, reading, writing and cooking. He grows a four-foot square of vegetables and enjoys the fruits of his labor- his grandchildren. I heard him say once at a party, “Why did I not think of this sooner?” and then in perfect harmony with his form he said, “I am sure all the patients are well taken care of, but I do miss taking care of them.”
But he is missed in the trenches of medical care. When wounds and injuries and bad organs and rotten flesh take hold of the essence of life then they cry out for him in their thoughts and wish.

The relics of time hold bondage to the past. Memory is the metaphor of the past while hope is the distance before us. We hope to see the likes of him.

"Words without thoughts never to heaven go"
William Shakespeare, Hamlet, Act iii, Sc.3

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