The Zen of Surgery and Bicycle Repair

I spent summers during high school and the first half of college working as a bike mechanic.  I love bicycles, and since I’ve always been the kind of racer with all the natural gifts to consistently finish last, I spent a lot of time fixing and tuning other people’s bikes.  The guys who taught me how to fix bikes were professional, passionate mechanics, dedicated to their craft and absolutely, batshit crazy.  As a young and impressionable adolescent, I was schooled in the ways of life, women, and bike repair by this motley gang.  Amongst other things, they taught me how to kill a fly twenty feet away in midair by creating a flame thrower from a large squeeze bottle of WD40 and a butane lighter.  They also taught me how to put out a fire in a confined space filled with flammable liquids.  And how to swear. Minolta DSC After the first year working with these proud professionals, I began to realize the difference in approach possessed by certain mechanics.  When I was confronted by a difficult challenge, I’d seek advice from one of the older, wiser mechanics.  Of course, they were all older and wiser.  Often, this mentor would advise me to simply remove the malfunctioning part and replace it.  Quick and easy.  However, a couple of the more senior, seasoned mechanics, the guys who were still doing this after many years (with brief interruptions doing time in jail due to other, part-time occupations), would show me how to actually fix the offending part.  Often, this repair would involve the deft application of a hammer and screwdriver, or a hammer and wrench, or hammer and an awl.  Always a hammer, deftly applied.  The repair was elegant, effective, and a lot cheaper than replacing the whole part. It wasn’t long before I realized that there was a world of difference in the approach these two types of completely competent mechanics would take to a difficult problem.  Both would end up with a perfectly functioning bicycle.  The “replacement mechanics,” however, cost the shop and the customer a lot more money.  These guys were also the ones who always were in need of some special tool or wrench, the little used tools that were always squirreled away somewhere.  They spent a lot of time looking for the exact tool that was needed to remove a bottom bracket or a gear cluster.  The other guys though, the “fix-it mechanics,” never seemed to need more than a hammer and a couple of basic tools to make the most intricate repair on the most expensive Italian racing machines.  And they did it cheaply, quickly, and half the time while hung over or higher than a kite.  This impressed me.  I always strove to be a “fix-it mechanic” whenever I could.  I also built myself a damn nice racing bike from all the parts the “replacement mechanics” chucked into the broken bin.  Still consistently ended up last. Many, many decades later, I have found the same phenomenon amongst surgeons; surgeons of every type and specialty.  I can truthfully say that it is very, very rare to find a truly incompetent surgeon.  In my nearly thirty years of practice, I can think of only one, as a matter of fact.  Oh, I’ve run into a lot of surgeons that I wouldn’t let operate on my dog, don’t get me wrong.  Many surgeons are arrogant (see Mommas, Don’t Let Your Babies Grow Up To Be Surgeons post on this blog), lack any semblance of beside manner, or are incapable of admitting when they screwed up.  Some lack good judgement or have personal issues.  But not truly incompetent.  When faced with a sick patient needing surgery, almost every surgeon that has successfully completed an accredited residency will manage to do the right thing. But like in the bike shop, they don’t all do the same right thing. I remember a case during my training that illustrates the point.  I was a fourth year resident on the trauma service.  In my training program we saw a lot of trauma, so by the fourth year we were fairly competent in patching up holes in people made by various firearms.  On a summer Sunday morning, a young man was brought to our ER with a recently acquired gunshot wound to the flank.  I forget the exact story, but I can confidently say that the young man was simply shopping for groceries with the several hundred dollars rolled up in his pants, given to him by his grandma, when he was jumped in the alley by two dudes.  It was always two dudes, because the victim would’ve blown away a single attacker and gone on to the grocery store to buy his grandma’s groceries, no problem.  Pretty much the same story every time. Anyway, this otherwise healthy seventeen year old comes to the ER bleeding pretty impressively from his flank wound and in shock.  My Chief is tied up with a list of operations left over from the night before so he asks the attending to staff me on the case.  Usually, this would be a great opportunity for me as almost every attending surgeon at this hospital was an expert in trauma care and a great teacher.  Almost every one.  On this morning, I have the bad luck to be staffed by a newly hired attending, a young general surgeon fresh out of residency/trauma fellowship at a very prestigious Midwest academic medical center.  Unfortunately, it was the kind of medical center that doesn’t see a lot of penetrating trauma.  The kind of program that writes a lot of textbook chapters, publishes a lot of esoteric medical papers, but doesn’t do a lot of operating. My attending, Dr. Maisy Blue, is not happy.  It is early on a sunny Sunday morning and she was planning on spending the morning in the call room “catching up on work”; she is quite distressed that the Chief has “dumped” this case on her.  As we explore the patient’s abdomen, we discover that he has a through-and-through gunshot wound to the kidney with a collection of blood (hematoma) rapidly expanding within the capsule enveloping the kidney.  The good news, though, is that the bullet has only injured the single kidney and otherwise exited the young man without incident.  Pretty straightforward case, one that I’d participated in on a fairly recent occasion.  I confidently outlined my plan to isolate the blood vessels carrying blood to the injured kidney, to be followed by repair of the organ.  “No way,” Dr. Blue, counters, appearing quite uncomfortable with my plan.  “He’s lost too much blood already.”  She is clearly distressed as we watch the hematoma expanding. “It’s going in the bucket.  He’s got another one, right?”  I quickly check to make sure that this young man is not one of the few individuals born with only one kidney and confirm to her that he indeed does have another, uninjured kidney, but– No ‘buts’ about it, Dr. B has already begun to dissect the capsule surrounding the injured kidney, resulting in a large gush of bright red blood.  She clamps her hand around the kidney, holding pressure.  “Take it out, Geller,” she instructs.  Which I do, clamping and tying the necessary blood vessels.  Once freed, Dr. Blue ceremoniously plops the kidney into a stainless steel basin.  “Done,” she pronounces.   “You can close with the medical student, right?”  No problem.  Young man did great, went home to his grandma three days later with a really cool scar and one perfectly good kidney.  Which should do him nicely for his whole life, really.  Unless somewhere down the line he gets kidney cancer, or has the bad luck to get shot in the other flank.  Should be fine. I just would rather fix it, that’s all I’m saying.

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