Why no one tried to pull the gnarled pine branch out from where it stuck in young Phillip’s ear remains a mystery to me. And as it turned out, a very lucky mystery. Many people had the opportunity to do so before I first met eight-year-old Phillip and his mother, Martha, in the pre-op suite of the hospital where I work. Phillip and his brother Jack had been playing catch on the beach near their home. Jack threw a long, perfect spiral. Phillip rotated and dashed full speed to catch his brother’s toss. He was so focused on the downward arcing football that he never even saw the pine tree he ran straight into, one of whose branches impaled itself into his ear.
Jack told his mother Martha, then others, then me later on, of the scream Phillip made upon the branch’s entry, the loud thwack of his body hitting the tree straight on, then the sight of Phillip reflexively breaking the branch off that connected him to the tree and falling to the ground. Jack ran to his brother and saw Phillip crying in pain, blood pooling down from his ear, and the stick sticking almost two inches out from his bleeding ear. Imagining how much pain it would cause his brother, he couldn’t bring himself to pull the stick out. He called Martha, who came running down the beach and promptly began to sob when she saw her two sons, and Phillip in such pain. She, like Jack, simply did not know what to do. She called 9-1-1, and the EMS team arrived several minutes later. Upon arrival, the two paramedics told Martha they had never seen a stick stuck so deep. As the bleeding diminished, and Jack seemed stable though still in great pain, they also made the choice to leave it alone, and brought Jack and Martha into the hospital where I first met them.
What struck me on meeting Phillip for the first time was just how normal he appeared given that he had a significantly sized tree branch piercing deep inside his ear. I knew that if the branch had entered just a few inches above it would have entered into his brain and his predicament would be far different. A few inches lower and it would have cut his facial nerve, paralyzing that side of his face. He could open and close his mouth. He even seemed to be able to hear. So where exactly had it travelled?
We spend so much time in medicine practicing, preparing, training for the expected and known, but what about when we encounter the unexpected and the unknown? Our hope is that such practicing and training will produce better outcomes: we will save more lives and lose fewer. Early on, we feel the flush of pride in our successes. But each additional encounter with the unknown brings us inevitably closer to an encounter we cannot master, a patient for whom there is no treatment or cure. With that first unsuccessful encounter, we are forever changed.
After more than twenty years in medicine, I know of almost no colleague who has emerged unscathed. We carry on, we practice more, we try. Mine is a forever humbling profession, where, even after we think we have seen everything, a patient comes in with something we have never encountered. We are confronted and perplexed: With all our experience, with all our practice, what will the outcome be? What to do now?
“Are you going to be able to pull it out?” Martha asked almost as soon as I arrived. I felt her dismay when I told her I needed a little more time to gather some information before I would know what to do or how. She had come to one of the finest hospitals in the country, and I represented one of the hospital’s senior, able emissaries. I imagined she thought I would be the one to confidently reach down, grab the offending stick, pull it out safely and cleanly, and end this nightmare. Instead, I told her I wanted to get a CAT scan to be able to see how deeply the stick had travelled and what structures lay nearby.
When the CAT scan returned and I traced the stick’s path, I could not help thinking of a book I had read years ago, and a scene that had embedded itself within my memory. In Gabriel García Márquez’s One Hundred Years of Solitude, Colonel Aureliano Buendía attempts suicide by shooting himself in the chest. Yet, in Marquez’s magical realism, the bullet improbably finds the one perfect course between the two ventricles of the heart: “The bullet had followed such a neat path that the doctor was able to put a cord soaked in iodine in through the chest and out his back.” Buendía survives.
Phillip’s story, however, was drawn from real life, not the magic realism of Marquez’s imagination, yet the branch that had pierced through the bottom of his ear canal had somehow, also improbably, missed the inner ear altogether. It passed deep to the facial nerve whose branches lay just above and directly in between the bifurcation of Phillip’s carotid artery where blood coursed from his heart up to his face and brain. The CAT scan suggested that there was perhaps a millimetre between the branch, those two great vessels, and the similarly large and important jugular vein immediately adjacent. I closed my eyes when I imagined what might have happened had Phillip, Martha, or even I grabbed that branch and just pulled.
If doctors and health-care practitioners train to prepare for the known and the unknown yet still can feel unprepared, imagine how the patient must feel when faced with those same uncanny encounters. Martha gave me insight into this when she said she felt like Job who asked of God: “Why have you made me your target?” Why Phillip? Why her? Why now? There are, in fact, quite a few times a day when so many of us might just as easily ask ourselves: “Why not”? There are so few of us who can’t recall a moment during a long drive when our mind wanders somewhere dreamily, for one moment, for two, for how long we are not sure, and we forget we are driving and lose our focus on the road ahead. A few moments later, we give a start and regain our focus and wonder what kept us from crossing the double lane to the other side, toward a very different unknown.
Once we accept that the situation is what it is, and fate has played her hand, the next challenge a surgeon confronts is how to explain the surgical unknown with the various pathways and possibilities. I explained to Martha that we actually use the words “known” and “unknown” in surgical planning. We first determine the known vital structures lying just beneath one’s incision, both to avoid injuring these and to use them as landmarks to embark on the new task at hand: journeying into the unknown. In this case, I would make an incision in Phillip’s neck and explore his neck to locate his carotid artery, jugular vein, and other vital structures, and to place rubber-band-like vessel loops around to constrict them and control any brisk bleeding if I injured them, while searching for the branch and then trying to remove it. The question I at this moment faced—the question all surgeons face—was how to adequately convey all the risks I knew were possible: significant bleeding needing transfusion, the small but horrible risk of exsanguination, stroke, or nerve injury, just to name the worst possible scenarios.
I explained everything as best I could to Martha then proceeded to the operating room with Phillip. After “prepping” his skin to keep the surgical field sterile, I used a scalpel to open his neck and found his vital structures. I then followed the course of the stick as it pointed down through the bottom of his ear canal toward the depths of his neck. The pre-op CAT scan helped direct me. The stick had indeed penetrated exactly between the bifurcation where the pulsating carotid artery divides to send one branching vessel to the facial structures and another internal branch directly up to the brain. What the CAT scan did not show, and could not have shown, were the tiny spines along the branches that looked like the barbs of a fishhook. I am not an expert fisherman, but I recognized the danger in those backward-facing barbs. As a fishhook is designed to keep a fish from sliding off too easily, so too the barbs on this branch held on to the tissues and structures it had penetrated. All I could do was place vessel loops around his common, external, and internal carotid artery, and then his jugular vein, to pull each of these great vessels apart from each other, as far as they could be stretched without tearing, to try to tease the barbs of that branch away. Closing my eyes for just a moment, I imagined the worst-case scenario of a major tear. I then imagined the best-case scenario of a clean, bloodless removal.
At that moment, Phillip, Martha, and I had two disparate realities, each of which was possible. In other times, with other sets of children and parents, and similar challenging crossroads, I have experienced both “realities.” I remembered the words from another surgeon, Dr. James Doty, who in his autobiography Into the Magic Shop describes being faced with near uncontrollable bleeding in the brain of a young child. If he placed a clip incorrectly in that pool of blood, the child’s life would be altered forever. Yet he had to place that clip. What did he do then and what must I do? Doty writes that he “calmed” his mind, simply did not “accept that this four-year-old is destined to die today on the operating table,” and followed the premise that “we train the mind, and the mind trains the body.”
Those words resonated deeply within me, and continue to do so, reverberating through my head at just such crossroads moments. I knew that stick had to come out. I also knew there was much at stake. As a much younger surgeon, I used to prepare for surgery by repressing the thought that I might cause damage in my attempts to help. I tried only to focus on the job at hand—as if the brain is such a simple organ and a surgical scalpel can separate it cleanly from the mind. My efforts and actions always seemed to trigger the opposite reaction I sought, as I felt my pulse begin to race and struggled to keep my emotions in check. Freud might have laughed at my attempts at repression. I had to find another way, to seek deeper within myself, face my own fears, and find some way not only to live with them but to be able to acknowledge them, and then move beyond them. I had to learn how to train my mind to allow it to train my body: to train the fingers that wielded the scalpel. If the child’s life on the table might be forever altered by my next set of moves, still the cascade of events that had forced these decisions to be made had started well before I entered the scene. I trained myself to step away from the moment for just that one necessary second, to allow myself to breathe.
I had to learn how to train my mind to allow it to train my body: to train the fingers that wielded the scalpel.
If it sounds easy or straightforward, I wish it was. Time (i.e., increasing encounters with the unknown) and fortune (or misfortune) provide the possibility, perhaps even the likelihood, of encountering roadblocks along the way that will challenge our ability to breathe our fears of the unknown away. Only a few years ago, I led a team of high-risk obstetricians, anesthesiologists, and other health-care practitioners all working together to help a woman safely deliver a child when a prenatal ultrasound had identified an enormous mass obstructing the fetus’s face, mouth, and neck. My job was to surgically establish an airway as soon as the child was born. I had entered the unknown, knowing that there was little chance of success. The mass was too big, and the time between the child’s birth and his need to draw a breath and get life-saving oxygen into his lungs too short. I brought the team together (including the parents) before the delivery began, and we went over what needed to be done. I reminded everyone of the risks and that there was a very real possibility that this child would die. Nevertheless, I knew the team felt more at ease because they had seen me successfully carry out this procedure before. For my part, knowing all the risks, I felt deep in my bones that I would find a way. I was wrong. The child was born, and my scalpel could not find an airway when none was there to be found. The mass had occupied that space in the developing fetus where the child’s windpipe was supposed to have developed and there was simply no connection between the child’s mouth and lungs. When we recognized this, I stopped the surgical exploration and quickly sutured up the incisions to make the child presentable for his mother to hold, if just one time. I felt everyone’s eyes on me. I felt their deep disappointment and sadness, and my own. I could tell myself that, on that day, in that circumstance, there truly was no live-saving way to be found, and nothing I could have done. Still, I left seared with a newfound respect for the unknown. I would go on to other patients and other encounters, but I would remember the words of another surgeon-author, Richard Selzer, from his book Mortal Lessons, that “[the surgeon] may continue to pretend, at least, that there is nothing to fear, that death will not come, so long as people depend on his authority. Later, after his patients have left, he may closet himself in his darkened office, sweating and afraid.”
It isn’t always this way. Most experienced surgeons will look to find ways to minimize risk. The stakes are too high and the unknown too unforgiving. Sometimes the best thing to do in the moment is to do less, to back away when the risk of damage is simply too great to justify the procedure. I remember taking a young fellow surgeon through a different case, this time not with a branch, but rather a rock-hard ball of tumorous tissue stuck onto the very same vital structures. It was difficult to tease the tumour free from the facial nerve and the carotid artery. This child’s life, and ours, were at a crossroads. I heard the breath of the fellow quickening. I asked him how he wanted to proceed. He began to describe the steps necessary to remove the whole tumour cleanly, and I quickly realized that he was already journeying down the frightening rabbit hole of the daunting task ahead—so much so that he had lost sight of the bigger picture. I needed to help him to step back. “Okay, I know you could go that direction, but let’s imagine what would happen if something went wrong if you did proceed?” I took him through the exercises I go through myself in my own mind when I am alone with my scalpel. In this case, it was clearly not worth the risk of all the pulling and dissecting. All we needed that day was a piece of tissue to make a diagnosis, not that satisfying full excision. This child’s disease was most likely lymphoma, and there were nests of other such tumors elsewhere in his body. The successful treatment of this child would lie with systemic therapy, with chemotherapy. The fellow cut a small piece from the top of the tumor, enough for a diagnosis to be made, and we closed the wound.
But in Phillip’s case, there was no option on the table other than to plunge in, as incredibly risky as such a move would obviously be. I had long ago stopped waiting to hear what my surgical instructor would advise; he was no longer there, and I was the one who had to make the decisions, wherever they would lead. It helped me to face what was at stake: these “vital structures,” as we say in medicine, were vital because they allowed Phillip not just to get needed oxygen to his brain but therefore to think, to laugh, to live his life. They allowed him not simply to move his face in some random motion, but to crinkle up his eyes, smile, and “be” the Phillip that Martha, Jack, and all his friends knew so very well.
To lower my own pulse and make the surgical decisions and actions necessary to remove that branch, I did not need to merely imagine things going horribly wrong, but to see that scenario vividly, to live it, to allow it in. Then, I needed to retake control, breathe, and feel my pulse lowering. I used all the breathing lessons I had learned after countless hours of operating to ground myself in my two “me”s: the one “me” outside myself, understandably terrified by the enormity of the task ahead, and the other, carefully constructed “me” who had to take charge, knowing that if my heart raced and my nerves betrayed me, then so too would the nerves of every other member of the operating-room team. I was not just playing a role; I was choosing to “be” the surgeon who knew the stakes, but who calmed himself and others by talking through what would happen if something did go wrong, how we would handle it together, and then by proceeding. I reclaimed that “me” and moved forward with the procedure. After separating those vessels to the point that they strained at my tugs, I was able to separate the pitch pine branch cleanly from where it lay and pull it free.
Phillip woke up after the procedure with a small scar on his neck, the only visible witness to all that had transpired during the past several hours. So much had happened to him, to Martha, to Jack, and to me in such a short time, but all that physically remained of his having crossed over from the brink of the abyss back into safety were six small stitches embedded under his skin where I had made my incisions; even these sutures quickly dissolved by themselves with time. The gaping hole in the bottom of his ear canal where the branch had penetrated healed so well that it was reduced to a fine white line, all but invisible to the naked eye. His facial features were unaffected, and his large smile when he saw his mother was perfectly symmetric. For herself, Martha carried the larger scar, the post-traumatic wound of a parent who has faced the terrifying prospect of life forever altered by one violent event.
And for me, as I watched the two of them together in the recovery room, I knew that Phillip, like Colonel Aureliano Buendía, had magically been spared by fate, but that, for Phillip, an entire non-magical set of conscious choices had been made, in which those very real alternate possibilities were imagined and inhabited, and then breathed away. I gave a small thanks to the years of OR experiences that had helped me to learn how to prepare myself mentally, and thereby physically. If one definition of an experienced surgeon is one who has forgotten his or her countless successes but vividly remembers the failures, then other words Richard Selzer wrote in that very same book, Mortal Lessons, hold as true today as they did when he wrote them: “There is no more sorrowful man . . . [than the] surgeon who has discovered the surprise at the center of his work. It is death.” When faced with the unknown, with either Dr. James Doty training, practicing, then breathing before placing that clip, or my following suit before removing that impaled stick, training the mind is our very worldly attempt to redefine the “experienced” surgeon. This person has the wisdom of one who can close his or her eyes, remember the successes as well as the failures, and retain humility and trepidation in face of not knowing which outcome the present day will end with. When we can respond in this way, the body finds a way forward, and we are equipped to forge ahead into the unknown.
This piece reflects the author’s present recollections of experiences over time. Some names and characteristics such as age and sex have been changed to anonymize the characters, and some events have been compressed.