Chapter Four

August

There were certain surgeons to whom every resident at Mayo wanted to be assigned. Tom Hale and Antonio Romero were up-and-coming stars in the department. They loved to teach, and they let their residents do a lot of operating. Fred Hastings and Garrett Freiberg were world-renowned hand surgeons. Bob Filmore was making a name for himself in the world of shoulder surgery. But the plum of them all was Mark Coventry.

Mark B. Coventry was the towering figure in the Department of Orthopedics at Mayo. Tall, distinguished, and white-haired, Dr. Coventry had a regal bearing that seemed both natural and deserved. So commanding was his presence that even some of the other attendings couldn’t bring themselves to call him by his first name. He had pioneered a number of surgeries, and had performed the first total hip replacement in the United States. Although in the twilight of his career, Dr. Coventry was probably the most highly regarded orthopedic surgeon in the country. In mid-August I finished with Dr. Harding and started with Dr. Coventry.

From the very first day on his service, I loved being with Dr. Coventry, but I trembled to think what would have happened if I had been assigned to him first. He would have been appalled at my ignorance. Where Dr. Harding largely ignored me, Dr. Coventry constantly challenged me.

“What muscles are innervated by the L-4 nerve root?”

“What is a MacIntosh procedure?”

“How much does a short leg cast weigh?”

“What is the minimum acceptable hourly urine output in a post-op patient?”

Dr. Coventry demanded a lot from his residents. If there was a problem with bleeding, drainage, pain, or an abnormal lab, God help us if we didn’t know about it, have an explanation for it, and have already instituted treatment for it by the time it came to his attention. These high standards were Dr. Coventry’s way of reaffirming the importance of what we did. By his attitude, by his bearing, and by his insistence on perfection, he impressed upon us the seriousness of our calling.

In addition to being a renowned surgeon, Dr. Coventry was a splendid athlete. He had been a standout hockey player at Michigan in his undergraduate days. When he moved to Rochester he played semi-pro hockey for the legendary Rochester Mustangs. He told me the only reason he quit playing was because of pressure from the Clinic. After a particularly rough game, the headlines of the Rochester Post-Bulletin sports section read: “MUSTANGS WIN. MAYO DOCTOR IN BRAWL.” That was the final straw for the Clinic administrators who objected to the unfavorable publicity. Dr. Coventry was forced to give up his hockey career.

Jim “Whit” Whitmer was the senior resident assigned to Dr. Coventry’s service with me. Since Dr. Coventry insisted that his residents make “pre-round” rounds each day, Jim and I would meet every morning at six. We would see every patient on the service, and then meet Cuv, as the residents called him behind his back, for formal rounds at 7:30 A.M.

I had been on Cuv’s service for two weeks and was preparing to see a patient when I found a strange-looking X-ray of the pelvis. “What the hell?” I muttered to myself. On the right side I could see a typical total hip replacement. On the left was a normal-looking hip except for wires around the greater trochanter. All hip replacements at that time involved wiring the trochanter at the conclusion of the case, but I had never seen a trochanter wired without the hip having been replaced.

I called to Jim Whitmer who had just come out of a dictating booth. “Hey, Whit, get a load of this.”

He walked over. “What’ve you got?”

“This,” I said, pointing. “Look at that left hip. It looks like—”

“Thomas Rodnovich,” he said immediately.

“Thomas what?”

“Rodnovich. Thomas Rodnovich.”

“You know the guy?”

“Everybody knows Thomas Rodnovich.”

“Okay. Who is he? And why does he have wires in his left hip?”

Whit took a step closer. “Listen,” he said, lowering his voice and looking to see if anyone else was around, “I can’t believe you never heard of this case. He’s a guy Cuv operated on last year. It was the last case of the day. Maybe everyone was tired, I don’t know. Anyway, the case was done in a second room, and the residents somehow prepped the wrong hip. To make it worse, Stan Warczak, the junior resident, put the X-ray on the view box backward, making the right hip look like the left.

“Cuv came in after the patient had been prepped and draped. He made the incision and had just removed the greater trochanter when he sensed something was wrong. He had one of the nurses check the consent and then realized he was doing the wrong hip. Thank God all he had done was open it. He hadn’t replaced the joint, but he had made an incision and had removed the trochanter on the wrong hip.”

I could hardly believe such a catastrophe had happened to one of my idols, one of the gods of orthopedics.

“So what’d Cuv do?”

“He didn’t say a word. He wired the trochanter back down, closed the incision, and did the other hip. Then he went out and talked to the family. He told them what happened and took all the blame himself.”

Since my first day in orthopedics I had worried about what horrible things might happen if I screwed up. This story made me realize that my fears were justified. People do screw up. Terrible things do happen.

I was afraid to ask the next question. “What happened to the residents?”

“Warczak went to Cuv after the case and apologized, said he was responsible for the error and offered to resign from the residency program.”

My heart was pounding. Resign from the program!

“Cuv heard him out and then said Stan had made a serious mistake. He should have paid more attention to what he was doing. But Cuv said he should have caught the mistake himself. He told Stan not to resign, but said God help him if he ever made a mistake like that again.”

I had just reached over to the X-ray to point at something when Whit whipped the film off the view box.

“Hey! I wanted to—”

“Gentlemen.” Cuv had come up behind us and nodded his hello. He took the X-ray out of Whit’s hand and put it back on the view box.

“One should never be afraid to confront one’s mistakes, Dr. Whitmer.”

Whit, embarrassed, nodded weakly.

“Dr. Collins, you have heard the facts of this case?”

“Yes, sir.”

“And what have you concluded?”

I was about to say something patronizing about how bad breaks can happen to even the greatest of surgeons, but the look in Cuv’s eye told me he didn’t want bullshit. I took a deep breath.

“Well, sir, it scares the hell out of me.”

“And why is that?”

“Because I’ve always been afraid that I would make some terrible mistake. This case is like my worst nightmare come true.”

He nodded. “You owe it to your patients never to lose that fear, Doctor.”

He reached over and straightened the X-ray, as if giving it permission to beam out his error to the whole world.

“This,” he said, “is what happens from a lack of vigilance on the part of the surgeon.” I could tell he was speaking as much to himself as to us. “Everything that happens in that operating room is your responsibility. Everything. On the operating table lies an unconscious, helpless patient who has placed his confidence and trust in you—not in the resident, not in the anesthesiologist, not in the institution, but in you.”

His shoulders sagged. He was visibly shaken. Even a year later, he was still suffering from what had happened that day. Whit and I looked at each other. There was nothing we could do to comfort him. Any words mere residents could say would only make it worse.

“Gentlemen,” he told us, “you will find that you can learn much more about yourself from your failures than from your successes.”

 

If there had been any doubt in my mind about going into orthopedics it was removed on Mark Coventry’s service. He showed me how rewarding and fulfilling life as a surgeon could be.

I had chosen surgery instead of internal medicine because I wanted to do things. Too often internists seemed interested only in the process of discovery. They wanted to learn things. What was the diagnosis? What caused it? The emphasis was always on examining and discerning, not fixing. “Internists diagnose and surgeons treat” is the old expression. Of course, internists put it another way: internists think; surgeons act.

Back then, orthopedic surgeons had the unfair reputation of being the dummies of the medical profession. We were the not-very-bright plodders who fixed broken things. Orthopods, so the internists claimed, were usually ex-jocks who were “strong as an ox and twice as smart.”

I attended Loyola Stritch School of Medicine in Chicago. Every year on the feast of St. Luke, the patron saint of physicians, the school held a big dinner. Skits were performed lampooning each specialty. Jokes would be made about anesthesiologists passing gas. The obstetrician would wear a catcher’s mitt. The pediatrician would have a lollipop in her mouth. And always, the orthopod would be some big, dumb guy with a tool belt strapped to his waist. His only dialogue would be something like “Bone broke. Me fix.”

Despite the jokes about orthopedics, I felt drawn to it. I had always liked to work with my hands. As a child, I constructed models and forts and castles. I enjoyed building things, starting with nothing and making it into something.

On Dr. Coventry’s service everything came together. He showed me the nobility of our calling. He showed me how seriously we must take our responsibilities. But, above all, he showed me how wonderful it felt to do something for others.

I learned from Dr. Coventry to enjoy the time we spent in the clinic. Like most orthopods I preferred the operating room to the clinic. The OR was where our hearts lay. That’s where great things were done. What happened in the clinic always seemed a preparation for, or a postscript to, what we did in the OR.

But there was a difference with Cuv. Going to the clinic with him was a heady experience. Every day, in almost every room, were people he had helped, people who were so incredibly grateful to him. I couldn’t get over it. Just thinking that someday I might be able to accomplish similar things made me giddy.

Frank, Jack, and Bill were jealous that I got to be with Cuv.

“So what’s he like?” Jack asked me one Friday night at Tinkler’s.

“Well, he’s a no-bullshit kind of guy,” I said. “He’s always asking you questions, always checking to be sure you haven’t overlooked something. He seems kind of cold and aloof when you first meet him, but he grows on you. What’s amazing is seeing him with patients. He’s all business when he examines them; but when it’s time to sit down and talk, he’s a different guy. All the sternness is gone. You can feel his warmth, how genuine he is.”

I know Cuv must have had his failures, but I don’t recall ever seeing one. Even a guy like Thomas Rodnovich, upon whom Cuv had made a mistake, certainly could not be classified as a failure. All his pre-operative pain was gone, and he was delighted with Cuv and his care.

 

Whit and I had positioned, prepped, and draped Mrs. Bergmann for her total hip operation. We waited at the OR table while Gladys, the nurse who always worked with Dr. Coventry, gowned and gloved him. He approached the table with an air of quiet confidence.

He nodded good morning to Whit and me, then silently held out his hand. Gladys placed the scalpel in it. “Dr. Collins,” Cuv announced in his stern voice, “will make the incision.” He handed the scalpel to me.

I was stunned—thrilled, but stunned. I hadn’t expected it. Tired from being up all night, I was prepared for another routine surgery. I had been working with Dr. Coventry for almost six weeks. I knew the answers to all his pet questions, and was prepared for a nice, relaxing ride watching Whit and Cuv work while I mindlessly assisted. Suddenly I could feel my heart pounding. I had never made an incision before. I had never “cut.”

As residents, even junior residents, we wanted to operate. That’s what surgeons do—they operate. And until we got to pick up a scalpel and cut it was hard to think of ourselves as real surgeons.

Sometimes at the beginning of a case, while we waited for the attending surgeon to scrub in, we would stare at that gleaming steel blade lying on the Mayo stand. We longed to take it in our hands. We craved the power and skill it represented. The scalpel was a symbol of that other world that was waiting for us, the world of operating rooms and surgery, the world of “hot lights and cold steel,” as the older guys called it.

The attendings knew that every resident wanted to do every case. At the beginning of the quarter, the attending would observe his senior resident, assessing his competence and confidence, judging his ability to operate. If the resident seemed to know what he was doing, if he answered anatomical questions correctly, if he was attentive and respectful, the attending would usually turn over more and more cases to him.

As junior residents we dreamed of someday doing our first total hip or rotator cuff repair, but we knew it wasn’t going to happen until we paid our dues working the suction and the cautery, cutting sutures and maybe sewing the skin. Frank and Jack had already done a couple minor procedures. So far Bill and I had never even touched a scalpel.

Frank wasn’t very sympathetic. “They don’t make scalpels with training wheels,” he said. “Why you two dang fools are more likely to cut yourselves than the patient.”

I had sutured many times, had closed many lacerations, and now, finally, I was being given my chance to cut.

Cuv stepped back and motioned for me to assume the head surgeon’s position. Gladys, Cuv, Whit, the two anesthesiologists, and the circulators all stood watching. I could see Whit’s eyes smiling in amusement as he watched my uncertainty.

“Well, Doctor?” Cuv said.

I laid down the scalpel and felt the hip, searching for the landmarks I would use to make the incision.

Is that the greater trochanter? I thought in panic. She was fat, and it was hard to tell. I palpated her skin one more time before I took the skin marker from Gladys and drew a long purple line indicating where I would make my incision.

Cuv felt the hip and nodded his approval. I held out my trembling hand to Gladys who was obviously enjoying my discomfort. “Scalpel, Doctor,” she said.

Holding the scalpel gingerly in my fingertips, I prepared to make the incision.

“Not like that!” Dr. Coventry boomed in irritation. “You don’t hold it like a pencil. Put it in your hand and hold it like a man.” He took the scalpel from me and demonstrated, holding the scalpel deep in his palm.

Intimidated, feeling like I was failing my first big test, I took the scalpel and once again approached the wound. I glanced briefly at Cuv for reassurance, but his eyes peered unwaveringly from above his blue mask and told me nothing. I took a deep breath, brought my hand forward, then drew the scalpel down the long purple mark. I took my hand away and seven pair of eyes looked expectantly at what I had done. A tiny, superficial scratch that was scarcely deep enough to draw blood was etched along the length of the hip.

“What was that?” Cuv grated. I could see Whit laughing from behind Cuv’s shoulder. “At this rate we’ll be here all day. Push on that thing and make a decent incision.”

I grasped the knife, then realized I was holding it like a pencil again. I shifted it back, deeper in my palm. I brought my hand back up to the top of the mark and pushed with what seemed like reckless force. Once again I brought my hand down the length of the purple mark, afraid that at any moment my hand might plunge into the depths of the wound and cut several arteries and nerves.

We all looked again. This time I had at least incised down to the subcutaneous tissue.

“Very nice, Doctor,” Whit murmured in mock approval. Cuv stood straight and still, saying nothing. I leaned forward to proceed.

“Deep knife,” Cuv corrected.

Since the base of hair follicles may still harbor bacteria even after the skin has been scrubbed, the knife that is used to make the skin incision is considered to be contaminated. Once the incision is made, the “skin knife” is discarded in favor of the sterile “deep knife.” I turned to Gladys who was already waiting with the correct knife.

Down through the greasy yellow fat I drew my scalpeled hand. Whit and Cuv held the Israel retractors as I worked my way deeper and deeper. I could tell they were growing impatient. I told myself there were no significant anatomical structures in the area. I wanted to go faster, but I couldn’t. It was all too new. I was terrified that at any moment I might find myself staring in horror at the severed ends of the sciatic nerve (which I knew was nowhere near me).

Cuv restrained himself admirably. What was taking me ten minutes would have taken him thirty seconds, yet he assisted me silently and competently, pulling the wall of yellow fat back from the operative field, and using the suction to point my way.

Finally I reached the fascia overlying the hip. Cuv tapped the fascia with the suction. “Can you identify this structure, Doctor?”

“That is the tensor fascia lata.”

He gently edged me over. “And directly below it is…?”

“The vastus lateralis muscle.”

Cuv nodded, handed me the Israel retractor, and picked up the scalpel. “What is the innervation of the vastus?” he asked as he incised the fascia in one delicate stroke.

I was back to being a junior resident. My time in the spotlight had ended. This dog had had his day. I told Cuv the femoral nerve innervated the vastus. He nodded approvingly and said, “Well done, Doctor.”

Cuv had thrown me a crumb. He let me open. He had done the same for countless junior residents before me. It was a moment he probably forgot within a week, but for me that crumb was a gourmet feast. I had held a scalpel in my hand and I had cut.

I was a surgeon.