The Unnamed Surgeon
This piece has been submitted for publication and is under review. It is a response to a call for stories related to “tending to an open wound.”
“64-year-old woman with a history of juvenile idiopathic arthritis, here with us today for a total ankle arthroplasty.”
It was time-out on my first day and first surgery on my orthopedic surgery rotation. “Lillie, med student,” came out as a trembling chirp. I touched my hand to my chest -- where was my heart trying to run off to? I took a mental inventory: The resident and the attending were both gregarious and warm women, and they had made me feel welcome. And I wasn’t anxious for my own performance – I was on the last of my 3 surgery rotation sites, so I felt confident I knew how I could be helpful. As I listened to the pit in my stomach, gnawing and pulling at strings that made my hands shake, I realized it came from a deeper place: I had signed up for a foot and ankle orthopedic surgery “leg” of my surgery rotation because I had myself had 5 prior lower limb orthopedic surgeries – and on my first day, I was witnessing a surgery I will one day have.
As a teenager, I was in an accident that broke my ankle badly, among other injuries that luckily haven’t lingered as long. The first surgery to repair my ankle had gone awry – yet at first, the surgeons did not recognize this. Thinking I was healed, they encouraged me to walk on my leg for almost a year – my bones grinding together and worsening the damage. During this time, my care team denied my pain and my insistence that I truly could not bend my ankle – telling me I needed to work harder in PT. Finally, a mobile MRI trailer rolled into town and proved my inability to dorsiflex to the same people who struggled to force my ankle upwards twice a week.
The doctors slotted in numerous procedures to correct the mistakes and resultant damage. At the time, I had felt voiceless and dismissed, and I wanted as little to do with these doctors and their surgeries as possible. When my surgeon proposed lengthening my leg tendons to improve my motion as part of the next surgery, I vehemently refused. My parents agreed with me – but the doctor did not. While I was under for another surgery, despite repeated explicit dissents, the doctor lengthened my tendons anyways.
I have never felt such anger and disgust towards anyone in my life like I felt towards that orthopedic surgeon. But I also felt disgust towards myself – I felt violated, and endured the constant, tugging reminder of the procedure every time I moved my leg. On bad days, Charlie horses unlike any I had ever had would remind me how broken and useless and not-mine my body was. I decided the only way that I could live with what my surgeon had done was to purposefully forget they existed. So far, I had done an incredible job of this: I had the same surgeon for 2 years with regularly-scheduled appointments, and I didn’t even remember their name.
I had more surgeries after that – to remove hardware, which I learned in my ortho rotation was a good idea and maybe I should have removed sooner – and to continue to fix the resulting complications from my initial surgery. When I finally sought care outside my small hometown, the doctor at the fancy academic medical center told me the realities: The damage had become chronic and self-perpetuating, and without intervention, I would see my ankle function diminish. If I wanted to walk, I would continue to need occasional surgeries for the rest of my life. Eventually, if I were privileged to grow old, I would need a full ankle replacement.
In this context, I knew that foot and ankle ortho could be a difficult choice emotionally for my surgical rotation. But I wanted to be an advocate for those patients specifically, and maybe to give a face and a story to patients that, based on my own experience, could become depersonalized by their doctors. And if I couldn’t do that, at least I could get some insider info to inform surgery number 6.
Yet I had not expected this exposure therapy to begin so soon – confronted with my future on the operating table. As the medical student and the patient at the same time, I had many questions — but I tread lightly. I double-checked my words before they left my mouth so that they did not sound too personally-oriented — yet I was simultaneously selfishly, ravenously curious. “What are outcomes like for this surgery in terms of movement?” “What is recovery like?” “So it’s mostly about pain, rather than function?”
I was shocked by the brutal precision of it – the shredding away of the talus, the hammering of intricate metal pieces into various bones, the numerous X-rays before and after each screw. The resident and attending were skilled in a way I had never witnessed before – a combination of intense physicality, measured precision and thoughtfulness in each step. They continued sharing facts about this procedure and others, about the patient and her disease. They invited me to participate with them in their field – and I found myself, to my surprise, deeply enjoying it. I volunteered for more action in the med-student approved ways – holding limbs, suctioning liquids, retracting skin and tissues – whatever they needed me to do.
A sickly snap sang out, signalling that we had broken the patient’s lateral malleolus. It had grown soft and brittle from decades of disease — and we expected this might happen over the course of this highly physical surgery. Yet it was with horror that I realized I was the one holding the culprit instrument. “It’s all right,” the resident reassured me, “We knew it was weak, we knew it was a risk.” She swept her hands underneath mine, removing the retractor. “It’ll heal well with the rest of the ankle, before she’s weight-bearing.” Even as I remember it now, I can’t help but feel guilty – did she know this was a risk?
As the surgery neared a close, the doctor jammed the patient’s new ankle upwards, and unlocked a memory of the unnamed surgeon describing to me how she would test my tendons in the operating room. “If I can’t bend it past here,” she indicated on my foot with a protractor, “I have to lengthen them.”
“It’s too tight,” Present day’s attending orthopedic surgeon held the ankle in its farthest point of dorsiflexion – far less than 90º. “We’re going to have to lengthen the Achilles. Lillie, hold the leg up.”
It was over and done before I even realized that we’d begun. It was so fast, in fact, that at the end of the surgery, I asked: “Don’t we have to lengthen the tendons?” I thought maybe we had forgotten — that I might be reminding the team. The attending stared at me blankly. “We already did.”
I had more surgeries that day, but my mind stayed in that first operating room. They’d just lengthened those tendons like it was nothing. It was so fast, so procedural – to them, it really was nothing.
The next day, we met the patient in the inpatient ward. We discussed the course of the surgery — tendon lengthening and malleolus break included, and she nodded, smilling — happy and ready to go home. No disgust or anger or hatred. She probably never registered my name, but would certainly not be going out of her way to forget it.
I worked with the same three attendings for my entire ortho rotation – all of them exceptional doctors and kind people. But I worked the most with the surgeon from that first day – and eventually, while doing another procedure that hit close to home, I shared with her that teenage-me had been on the other side of some of these operations. I shared about my broken my talus and calcaneus — distancing myself with anatomically correct descriptions and vernacular, and allowing her to engage with my story from the surgical distance I expected from an orthopedist. She was peering over her surgical goggles and inside the patient’s leg, making precise moves with tools I didn’t know the names of. She paused abruptly. Scalpel held adrift, she turned to look at me: “But you walk so well!” What followed was a reversal of the typical roles: She peppered me with questions about how many procedures I’d had, if I’d had any complications, assistive devices I use and shoes that I wear. “That’s a pretty catastrophic injury,” she said – words blooming into validation that I think neither she nor I had anticipated. “I’m surprised you manage so well.”
I went home that day thinking about the unnamed surgeon. I wonder if I was the first surgery of the day, and when was the last. I think about the burnout I had seen among residents across specialties – but especially in those with a grueling intensity that require complex mental and physical labor, such as surgery. For some, I had seen that burnout turn into a void of empathy – unable to emotionally activate with so little gas to run on just to survive. Was that what happened to the unnamed surgeon? I think about the speed with which the practiced hands of the resident slid through the skin of the calf and made quick, precise cuts. It was less than a minute of her life. Why would she think that it would take up so much of mine? It might be hard to imagine it would matter at all.
Several weeks after my surgery rotation, I found myself wanting to know. I typed my hometown’s name and “orthopedists” into a Google search. The internet quickly provided – there they were. Anger filled my chest and sadness weighed on my shoulders – but bizarrely, I felt a new feeling arise. I felt I could understand my surgeon – maybe even empathize. It might even border on forgive.
That night, the Charlie horses screamed at me again – they still do, from time to time, especially on the walking-heavy rotations. As I stretched through the pain, I felt the tug of my scarred tendons. Rubbing the nubs of the scars and the aching muscle with my hands, I thought of nothing but the day to come.