The visceral reaction that one has when one experiences the inside of the body – seeing the guts laid out on the sterile blue towels when the surgeon “runs the bowel” as he performs an exploratory laparotomy – is not pleasant. It is a time of fear, the fear of you not being able to take it. That fear is associated with your autonomic nervous system. Not your conscious system by which you for example command the big toe to move up and down (which is the voluntary system). This other system is the automatic system, which runs itself. It controls your bowels, your time of awakening each morning, your stomach acid secretion, your blood pressure. Your voluntary nervous system can override your autonomic system to a certain extent.
Although I had removed the heads of several hundred chickens, ducks, and geese, as well as a pig to boot, and had dismembered each with nary a hint of visceral reaction (e.g. the queasy stomach, the inability to control yourself from fainting down to the ground in a cold sweat) I nevertheless felt that visceral reaction as second assistant on an exploratory lap. Here were the human guts right there an inch from my retractor, the abdomen open wide. I tried not to vomit, and not to faint. I bit my tongue; perhaps some pain would save the situation. And it barely did.
The automatic nervous system is very experienced. Perhaps two billion years ago, it began its development in starfish and sea life, which were very early in the evolution of the intestinal system. It is said that the G.I. tract has almost as many neurons as the peripheral nervous system has in the arms and legs, and approaches the central nervous system in complexity. So when I was in my first autopsy at Wood Veteran’s Administration Hospital in Milwaukee, Wisconsin, Department of Pathology, the dead human body lay naked, supine on a steel table looking up at the ceiling, with his huge relaxed penis there; it was difficult to take your attention away to the rest of the body. The smell in the autopsy room is a cross between the not pleasant formaldehyde combined with the inside of the bowels, which is the awful bathroom smell almost the same as baby shit. And when both the large intestine and the small bowel were opened, as well as the gallbladder and stomach, each thoroughly examined, weighed and described, my autonomic system reacted as if it had obviously had experience with that situation, perhaps 100 thousand years before my time at Wood Veteran’s Administration (VA) Hospital. My autonomic system had a response embedded in its nerves and reflexes, and was putting into effect an upset of my intestines. My voluntary consciousness was barely able to override that colon. But not easily; a lot was on the line.
You want to be a surgeon? Not someone who is flat out on the deck, having fainted, is a surgeon, nor one running to the vomit sink?
Contrast that with the open chest of a fat and alive dentist. The breast bone had been sawed open during the heart surgery 10 days previously and the opening was spread wide with a screw-type steel separator, all very sterile. But after the patient’s successful quadruple bypass, in which his leg veins were used to patch sections of the sclerotic coronary arteries to the heart itself, infection sadly occurred.
There is always a battle in every wound, of every body, each of us, with wounds to the body. The battle, which decides whether a wound, any wound, will heal, is between the three factors shown in this triangle:
Here we depict the interaction, really a battle universal in every wound.
And somehow, the dentist had lost that battle. He had an imbalance in this magical, sacred triangle. And the wound, the median sternotomy, did not heal; he was re-opened in a take-back surgery, the purulence drained. His chest cavity and the heart sitting there were washed out with several thousand CC’s of antibacterial.
You must not close an infected wound; the infection may thrive as it has the upper hand at this point. Some wounds with infections may be closed over a drain system, which instills things to kill bacteria but not kill the patient. But in this big wound it was mandatory to pack it open and then change the dressing daily.
Plastic surgeons as a species arrogantly state that “we are able to close any wound in the body; we can fill any deficit.” However the plastic surgeon has at his or her disposal only six operations, and using only these six we are known for the ability to close all wounds. The art of plastic surgery is in the mixing and matching of the six in what we term a “symphony.” All comers, all wounds, are able to be treated and fixed successfully. And we train 6 or 7 years after med school in order to be of service to patients who in turn “serve us.”
Excellent and careful fine technic exist for:
- wound closure, the first of our six operations,
- the second being split-thickness skin graft,
- the third, skin and soft tissue flap supported with its own circulation (veins and arteries are neither severed nor disrupted),
- the fourth, free-flap transfer of skin and subcutaneous tissue separated from its nerve and artery but re-sutured with the artery and vein (and usually the nerve also) to another sustenance and another (nerve) artery and vein in the same person. Microsurgery usually is required for the free flap transfer of chunks of tissue from one spot on the same person to another site because the arteries, veins, and nerves are small in size and magnification is necessarily called into play. Microsurgery, a relatively new component field in Plastic Reconstructive Surgery (PRS), was pioneered by our Stanford’s own Harry J. Buncke, of Clinical faculty, San Mateo, California, and his little group: engineer, former German wartime, probable rocket scientist (his resume was blank for years 1941-1947), nurse Nora Adams, and fortunately DRL himself in the infancy of his Stanford career. Werner Schulz “vass dee brilliant Chermahn” who invented then and there how to fabricate suture from human hair, and to swedge it onto a tiny needle. The surgeon’s tremor was abrogated with a pneumatic air pressure device operated by a foot pedal and a small air tube and air bag. Nora, HAB’s (Harry A. Buncke) nurse, arranged for our experimental monkeys from the SFO airport. They were in 6 week quarantine on their way to Jonas Salk in Cincinnati. Buncke was the driving force and the “prefrontal cortex” of the experimental microsurgery, Laub was assistant surgeon, Greg Buncke was in high school and helped as needed in the Buncke family garage operating room and in Peninsula Hospital basement during “operating room” hours (occurring after usual hours).
- Homotransplantation of organs from one individual person to another (different) human. This required medical science with basic research to alter the immunologic rejection of the organ in order to accept a foreign body, a transfer of a human part, person-to-person.
- Complex tissue homotransplantation, for example a face transplant, which is attracting the many plastic surgeons with their usual psychologic profile. (1)
These all are repairs which increase function and improve appearance; this is all we have as plastic surgeons. Our cognitive skills are said to be little in comparison to internal medicine or the sister specialties of cardiology, immunology, and infectious disease. (or God). We are called upon to mix and match these six types of operation and to tailor a certain plan which is different and unique for each patient. Herein is the beauty and the pleasure of our field.
But standing there, before a crystal blue October sky, I was looking out the window of the intensive care unit room. Also before me stood the ridge of the Santa Cruz, or coastal mountains, with the beauty of the ancient 100 year-old redwoods (not 1000 year old), and the long gully in front of the mountains. And just beyond the back of the hospital was the San Andreas Fault, an actual earthquake fault line, moving Los Angeles north 1 inch per hundred years, or even faster at the times of active quakes. The vineyards were out there on the hillside just 11 miles off my ICU room. I was comprehending the history of my view, perhaps a billion years have elapsed since they were formed. And the history of the human DNA, the human being one specimen carrying DNA with its primary mission to perpetuate this human genetic information, and in turn, my responsibility in this whole scenario and scene; I had taken the Hippocratic oath to give my priority to single persons with pathology and cure them with the skill and science I had learned in my sacred profession. I felt the weight of my assigned job. Although the patient had an endotracheal tube to breathe for him (necessarily because of an open chest), voluntary breathing being impossible, I could see the personality in his eyes and face, and could deduce details of his history. I had read his chart, the medical history: he was overweight, had arterial vascular coronary disease, had engaged in overwork, lack of exercise, and had no thought of preventative medicine in his life. No thought of wellness. I began to wonder about what it was exactly that civilization contributing here?
Civilization came to America, the Spanish, the English, the French, following the Iniut and others, who were more original stakeholders here. Civilization, as far as contemporary Western medicine is concerned, centers itself about the caring of guys in awful health, who have been successful in gradually killing themselves with the goal of the “good life.” Why not spend a billion or two, on preventing these cases with education and great programs? But who should do it? The government, with taxes? Or 501.c.3 foundations, with their donations? Both have responsibility to transform healthcare, from those who have it to those who really need it. And this dentist is a so-called “success story” in the modern civilization which has engulfed California. In actuality, this man is really a poster-boy for the re-alignment of resources.
But these emotional times must be spent on planning wound closure. I was myself alone in planning the wound closure. I felt great, in the sense that Dr. Gaudiania, legendary heart surgeon, had called me in. And I knew how to fix this patient! This was going to be a great case!
In my professional life ever since the day I was called to be an extern, staying overnight at the veteran’s hospital in Milwaukee, Wisconsin, to take call for any patient problems, I had been totally directed toward, and had made myself the personal goal of obtaining, good cases. Good cases would make me a great doctor with great experience. I desired to have more good cases than other doctors, in a competitive sense that I’ve had ever since first grade. The good case was quite similar to obtaining the Holy Grail. After a clinic, for example, I would always answer to the question, “How was clinic?”
“Great, I had three good cases.”
(1) Those in each specialty in medicine are characterized with a distinctive and typical psychologic profile. In plastic surgery, the profile is:
- Please the patient. Attempt to do what they ask of you in their CC (chief complaint)
- Do the impossible; nothing is impossible
- Any wound can be closed
- Your result, sir or madam, is really good