Don’t do that!

As part of my first year of medical school training, we were invited into the operating theater to observe a surgery. In practice, we stuck to the wall as far away from the operating field as possible, in order not to accidentally trip and fall face-first into the patient’s intestines. Nevertheless, it was a fascinating learning experience in the real world of surgery.

I have unfortunately spent a significant amount of time on the “family of the patient” side of the operating room doors. When I was in my late teens and early 20s, there were multiple occasions when I was waiting with the rest of my family for the surgeon to appear and tell us the news. At that point in my life, I was no different than anyone else in that I also saw those swinging doors as a magical gate into a world that most people would never see. I definitely was envious of the staff members who could freely go back and forth, in and out of the surgical area. The waiting was, as many people know, intolerable. I know that there are programs today that inform the families of the status of the patient being operated on. Especially in cases where the surgery drags on for many hours, just a few words from a surgical liaison can make all the difference between a panic attack and being able to, at least, sit down and have a coffee. Specialized mobile apps that allow for sharing of such information are greatly needed.

So here I am back in the operating room as a medical student, with a medical student colleague of mine, trying to be invisible but still trying to understand what is going on. I was fortunate in that my undergraduate degree before medicine, was in physiology. I had already studied a significant amount of anatomy and physiology and this helped me to appreciate more of what was transpiring in front of us. This specific surgery involved the removal of a section of the bowel which had a tumor. From a technical point of view, this was straightforward. There was a clearly observable mass in the far part of the bowel, and this mass along with a healthy section of bowel on each side of it, needed to be removed.

When you look at demonstrations of surgeries, presented as animations or even as static pictures in the textbook, there is one critical piece of information that the artists fail to specify. Specifically, it is never stated in an anatomy textbook that pictures don’t bleed. It is astounding how quickly a clean surgical field, with the anatomy perfectly laid out, can become a disaster movie, when a significant artery is clipped. Suddenly, the surgical field fills with blood. By definition, if you wait until the blood stops flowing to clear the surgical field, the patient is dead. So clearly, you have to act quickly to identify what it is you damaged, and then you need to repair it. This can extend the time for a “simple” surgery by minutes to even hours. And, if the patient was frail to begin with, such unexpected bleeding can lead to a whole range of life-threatening postoperative complications.

At the point that the surgical field was prepared and the bowel was about to be removed, we were allowed to step a little closer and peak into the inside of the abdomen. I was speechless [which is an extremely rare state for me]. Here for the first time, I saw living, moving anatomy. No longer was I trying to remember names on pictures in a book. Now for the first time, I saw how the diaphragm moved up and down with every breath. The perfection of the design of our internal structures, made me feel that we were very much creatures of a great designer. In other words, it really was a religious moment.

The surgeons continued to work and at one point, the more senior surgeon screamed at the more junior surgeon “don’t do that!!”. Suddenly, there was a frenzy around the operating table and I stepped back and grabbed the wall, practically hoping to become invisible. Orders were being screamed out, a constant demand for suction was being made and in a few minutes [which seemed much longer], the spleen had been removed and placed on one of the surgical trays. As new as I was to the world of surgery, it was clear to me and my colleague that this was not a planned step in the resection of the tumor. Quite simply, the younger surgeon slipped and cut one of the significant arteries to the spleen.

Things change in medicine and one of those things is the management of a damaged spleen. These days, it is considered appropriate and safe to repair a damaged spleen using some newer technologies that did not exist when I was a medical student. But 30 years ago, a bleeding spleen was removed because of the difficulty in controlling the bleeding and thus eliminate the risk to the patient.

The rest of the surgery went on as planned. The younger surgeon, as he was removing his surgical gown, asked the more senior surgeon what to say to the family. Without missing a beat, the more senior surgeon said that the family should be told that there was an unforeseen technical issue and the spleen needed to be removed in order to complete the operation. However, the senior surgeon continued and said, that removing the spleen made it possible to fully resect the tumor and as such, was a necessary sacrifice for the overall health of the patient.

From the family’s perspective, what they heard was that this was a difficult surgery requiring extra effort but thanks to the expertise of the surgical team, it all worked out for the best. I did not personally see the family immediately after the surgery but I strongly suspect, based on many other experiences I had during my surgical residency, that the family was ever thankful, and probably even kissed the hands of the surgeon. From the family’s point of view, their loved one was in danger and this young surgeon had just saved his life. I leave it to the ethical pundits to argue whether any purpose is served in telling the family the whole truth in such a case.

I thought of this incident after reading an article this morning about the increasing capabilities of surgical robots. I am well aware of literature that still questions the benefits of surgical robots, in terms of speed of the surgery and even complication rates. Purely on an anecdotal basis, I am personal friends with a surgeon who regularly uses the robot for a given procedure, and he states that the benefits are absolutely clear. In fact, he states that the surgical robot controls the environment so much and automates the surgical process to such a point that from the surgeon’s perspective, the operation becomes tedious and boring. In other words, the robot is so successful, that surprises are rare and the successful surgical technique is repeated exactly from case to case.

The obvious follow-up question is why there is still a need for the surgeon to be operating the remote surgical arms. I personally hope that within the next 10 to 15 years, there will be no need for human involvement with the surgical procedure. In this new fully automated scenario, every patient will benefit from technically excellent surgery. The robotic hands will not shake and they will not slip. The unnecessary removal of an organ due to a human error should hopefully soon become a distant memory.

In the next 10 to 15 years, it seems that driving will no longer be a human task as well. Robots that clean operating rooms and patient hospital rooms better than any human can will soon be commonplace. I have already seen real-life demonstrations of robots that distribute various materials to different hospital floors. Considering how many errors continue to happen in the distribution of medications to patients in hospitals, I personally hope that this entire process is quickly converted to being entirely digital. Despite arguments to the contrary, once a procedure has been fully digitized, initial bugs and errors tend to be quickly corrected, so that continuing use of the fully automated system truly is safer than the human equivalent. As I seem to say in nearly every blog post these days, I would not dare predict how life will be led in 20 or 30 years from now. I am willing to take a guess at how things will be in 2020. But that’s as far as I will go.

Even if I could peer into my predictive analytical crystal ball and tell the world what Marvel movies will be in theaters in 2050, I would not. Life needs to stay a bit mysterious. At least for us humans.

Thanks for listening

About the Author
Dr. Nahum Kovalski received his bachelor's of science in computer science and his medical degree in Canada. He came to Israel in 1991 and married his wife of 22 years in 1992. He has 3 amazing children and has lived in Jerusalem since making Aliyah. Dr. Kovalski was with TEREM Emergency Medical Services for 21 years until June of 2014, and is now a private consultant on medicine and technology.
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