An inside look of the mind of a surgeon
by Ismael Nuño, M.D.
Chasing ghosts in the operating room sounds supernatural, but it is actually something we surgeons really do. Each one of us has worries about what we are about to encounter in surgery. Will the case be technically difficult? Will the surgical anatomy prohibit us from doing a good job? Will we experience any complications? Will the patient die?
A colleague of mine once told me that disease is aggressive and that we had to be even more aggressive. In my younger and more inexperienced years, I would always wake up in the morning and begin to frantically think of all the details needed for my surgeries that day. The suture material, the anatomy, the difficulty of the procedure, and all the planning were all part of the preventive strike. My breakfast, shower, and drive into the hospital were all avenues in which to think and prepare. I still do it all each day that I am operating—which is every day.
There is a basic premise among surgical personnel that, with each case, there will be an expected or possibly unexpected set of bad things that may happen during surgery. What do I mean by bad? Perhaps a minor complication—or something as severe as a fatal complication—can always occur.
In surgery, we always joke that there are ghosts in the room. As daring as we are, we have the courage to chase away these ghosts by doing the best job possible. After all, we are the courageous people that will fight bad things, including death. We are the soldiers who will keep our patients safe. “Not during my watch,” all of us surgeons defiantly declare. We are the Spartans who will stand up to these bad ghosts.
Considering all of the possible mishaps is one of our duties. I am also a certified private pilot. We were taught in flight school that the best-prepared pilot is one who already made all of the decisions in advance.
Remember the US Airways jet that landed on the Hudson River? The pilot never showed any signs of panic or indecision and he safely landed the plane with no harm to anyone. Working in the operating room is a similar job to that of a pilot. You check out the equipment the same way a pilot would check out the airplane before flight. You set a destined plan of surgery, like looking at maps and the compass. During flight you are constantly aware of the instruments, just like you would be in the operating room. After all, like I said, a good pilot will have made all of the major decisions prior to taking flight. A good surgeon will have considered all the different possible outcomes before undertaking a surgical procedure. Professionalism, insight and instinct are all part of it.
The little things we do as surgeons also affect how the surgeries go. We begin by walking in with our head high. We are the captains of the ship. We greet everyone in the room with a “Good morning.” We bring in our favorite CDs and play the tunes that calm us the most. If nothing else, these tunes evoke good memories for us during surgery. Music can be anything from current rock to classical music. The louder the music, the more ardently and dramatically we chase away the ghosts and the bolder we are.
At one of the hospitals where I was on staff, a nun-turned-nurse would place glasses full of water at each corner of the operating room. When I asked her why she had this ritual, she answered, “It keeps the ghosts under control as their energy fuses in with the water.”
What would surgery be if we did not tell a joke now and again? Silly or not, it is part of the routine and it helps ease the tension in the room. Everyone respectfully laughs at even the stupidest jokes.
We prepare the patient, give the anesthetic and begin our daily work. We chase away ghosts the minute we wake up. The scrub suits and gowns we put on for surgery, the scrubbing of our hands and the sterility in the operating theater are all part of the process. We are mocking death and we are, at the same time, assuring ourselves that we are not anxious or nervous and that we can control our actions. Controlling our anxiety must be done first, before we can control the anxiety of others.
In a conversation with my father one day about surgery, he told me, “If you were aware of all you do to another human being during surgery, you wouldn’t do it.” I looked at him with an air of incredulity. I was young and passionate about wanting to be a surgeon. In my mind I had the model of ‘get in and get out’. That’s how you do surgery. You don’t consider all the possibilities. You do, but you don’t. You accept all the possible complications your patient may have but, at the same time, you prevent them. You prevent all of them if you can. As a surgeon, like my teacher told me, you have to be more aggressive than the disease.
At the end of the day, we slowly walk out of the operating room and, in the same way we did when we first walked in, we say “Good evening.” We look at one another, tired as we all are, and feel thankful that we were able to take a possible catastrophe and turn it into a successful outcome.
We then calmly go and, in a very poised fashion, greet the patient’s family and say, “Everything went very well.” At the end of the day, as we slowly walk out of the last surgery, we acknowledge the ghosts that visited that day, but take pride in having chased them away.
Ismael Navarro Nuño, MD, FACS, FACC, FAHA received his training in cardiothoracic surgery at Walter Reed Army Medical Center in Washington, D.C. He was chief of cardiac surgery and chief of staff elect/president elect of the Medical Association at the Los Angeles County + USC Medical Center, as well as assistant professor of clinical cardiothoracic surgery at the Keck School of Medicine. He is currently medical adviser for the Alfred Mann Institute of Bioengineering at USC, and was previously medical adviser for the St. Jude Medical Corporation for the Western United States. His latest book is, The Spirit of the Heart: Stories of Family, Hope, Loss and Healing