“ROBUST” was the word that came to my mind that morning as I caught my first glimpse of him. He was sitting on the hospital stretcher, struggling to tie his gown around his broad shoulders. Rather than appearing small and vulnerable, like most patients do awaiting surgery, he took up more room than the curtains afforded him. His thick torso, weighty hands, and roughened skin spoke of the nearly seven decades he'd spent battling the extremes of New England weather. He was an oak.
As I approached him in the preoperative holding area, he looked up at me and unexpectedly smiled.
And with that simple gesture he won me over before he'd spoken a word.
His last name was Albertson. “Everyone calls me Al,” he said by way of introduction. He stuck out his hand, and mine was quickly swallowed by the enormity of his grip.
“Al, a pleasure to meet you,” I smiled, and introduced myself.
I was a first-year resident in anesthesiology, and Al's surgery—to remove three cancerous lesions from his liver—was going to require more from me that day than any I had participated in so far. I had been in training just long enough to be nearly paralyzed by the quantity of physiology and pharmacology I needed to master, and the level of manual dexterity I had to achieve, but not long enough to have conquered the agonizing self-defeat that daily threatened to eat up whatever small victories I gained in these areas. I was constantly terrified I was going to do something—or worse not do something—that would result in death or injury to one of my patients.
As anesthesiologists, we are trained—more than anything else—to be vigilant. We stand at our patients' heads and attempt to keep every organ system in their bodies behaving appropriately. We oversee, survey, inspect, and examine. We manage, control, guide, and direct. And when something begins to go awry, we respond, evaluate, diagnose, and treat.
As a first-year resident I was still learning how to do all of these things, but believed that I ought to be doing them all perfectly. I arrived each morning and asked my patients to give me their lives—the greatest gifts they could possibly give me—all the while knowing I was not the best physician they could have received that day. I was only learning to be. It was the awareness of my own ineptitude—fundamental to any novice, and the profound privilege intrinsic to learning from a human life—true only within medicine, that haunted me everywhere I went. It followed me into every operating room and besieged my confidence daily. I knew my patients deserved better than me. But to become the kind of physician they deserved, I had to keep asking them to give me their lives, and bearing the risk of harming them. I had to stare my fear in the face, with a new set of patients, each and every day.
Dr. H had been assigned to mentor me upon my arrival in Boston six months ago. He lived to make his residents love anesthesiology, and he did so with immeasurable energy and passion. From our first day together, he sensed my fear and made it his personal endeavor to carefully, consistently etch away at it. Each day Dr. H and I worked together, fear's grip on me became a little less crippling and I, in turn, became a little more confident.
On this day, Dr. H had been assigned to oversee my care of Al. Al's case began uneventfully and had been going smoothly for much of the morning. Dr. H briefly stepped out to see another patient, but upon his return he immediately noticed distinct changes to Al's continuous electrocardiograph. I followed his gaze and my breath stopped short. Al was having a massive heart attack.
Panic began to build in me. I may have missed one of the most important, most common, life-threatening perioperative complications we see. Its incidence had been drummed into my head since the first day of residency, something for which I was to be watching more than almost anything else.
I loathed myself.
Dr. H notified the surgeons. Having just completed the removal of all three lesions, they immediately began closing Al's abdomen. He then called the cardiologists and shot a crushed aspirin down Al's nasogastric tube. As I watched him, I wondered how we would treat a coronary blockage. Anticoagulants any stronger than aspirin would be contraindicated in the setting of Al's surgically-injured liver.
My stomach churned with fear.
We packaged Al and his equipment and traveled to the catheterization lab in silence. As the cardiologists gathered around the pictures of Al's heart, Dr. H stood beside me, his unspoken reminder to me to keep breathing. A cholesterol plaque had broken free in one of Al's coronary arteries and traveled to its distal tip. Everyone agreed his body was doing a sufficient job of clearing the plaque all by itself, so no further anticoagulation would be necessary.
Dr. H looked at me. “Bottom line: not your fault. You didn't cause this infarction, and you couldn't have prevented it.” I looked down, tears of relief rising in the corners of my eyes, beginning an unabashed course down the sides of my face. “You learned something today. So when it happens again you'll know what to do. And that is exactly why you are here.”
In total, Al stayed in the hospital twenty-six days. That first night he looked small, naked, and defenseless. Tubes and lines crawled out of every orifice, and it appeared as if his bed were trying to swallow him. He was no longer the rugged New England outdoorsman I had met that morning. Instead, his frailty and debilitation made my own heart ache.
It took days before I could visit him without my hands shaking, weeks before doing so no longer induced chest pain in me. But slowly, over time, Al's heart began to recover. He started breathing on his own, then eating, then walking the halls. His body began to shed its lines and catheters, his hardiness returned, and within a few weeks he had found his smile again. Each day he improved I noticed my own heart hurt less.
Al's heart had suffered an injury so severe it nearly killed him. My own heart had become almost incapacitated by terror and self-defeat, even more so immediately after our experience together. But from him, I not only learned how to prepare for and manage perioperative complications, I witnessed what it meant to be robust. I observed in him the strength to fight his injury, the courage to overcome its hold on his heart, and the determination to take back his life. And by his example, I found the strength, courage, and determination to heal my own heart, and find its deeply-buried confidence. Just as his heart began to heal and move on, mine felt permission to do the same. Al finally went home, and I, too, recovered. Indeed, over the months and years that followed, the perseverance of his heart became eternally entwined in the perseverance of my own.
