My last day as a surgeon

I HOPPED out of the CT scanner, seven months since I had returned to surgery. This would be my last scan before finishing residency, before becoming a father, before my future became real.

"Wanna take a look, Doc?" the tech said.

"Not right now," I said. "I've got a lot of work to do today."

It was already 6pm. I had to go see patients, organise tomorrow's OR schedule, review films, dictate my clinic notes, check on my post-ops, and so on. Around 8pm, I sat down in the neurosurgery office, next to a radiology viewing station. I turned it on, looked at my patients' scans for the next day and, finally, typed in my own name. I zipped through the images as if they were a kid's flip-book, comparing the new scan to the last. Everything looked the same, the old tumours remained exactly the same… except, wait.

I rolled back the images. Looked again.

There it was. A new tumour, large, filling my right middle lobe. It looked, oddly, like a full moon having almost cleared the horizon...

Mapped out next steps

I was neither angry nor scared. I drove home and told (my wife) Lucy.

It was a Thursday night, and we wouldn't see (my oncologist) Emma again until Monday, but Lucy and I sat down in the living room, with our laptops, and mapped out the next steps: Biopsies, tests, chemotherapy. The treatments this time around would be tougher to endure, the possibility of a long life more remote.

Neurosurgery would be impossible for a couple of weeks, perhaps months, perhaps forever. But we decided that all of that could wait to be real until Monday. Today was Thursday, and I'd already made tomorrow's OR assignments; I planned on having one last day as a resident.

As I stepped out of my car at the hospital, at 5.20 the next morning, I inhaled deeply, smelling the eucalyptus and… was that pine? Hadn't noticed that before. I met the resident team, assembled for morning rounds. We reviewed overnight events, new admissions, new scans, then went to see our patients.

Afterwards, I spent an extra couple of minutes with a patient, Mr R. He had developed a rare syndrome, called Gerstmann's, where, after I'd removed his brain tumour, he'd begun showing several specific deficits: An inability to write, to name fingers, to do arithmetic, to tell left from right. Mr R was getting better, though: His speech had returned almost to normal, and his arithmetic was only slightly off. He'd likely make a full recovery.

The morning passed, and I scrubbed for my last case. Suddenly the moment felt enormous. My last time scrubbing? Perhaps this was it. I watched the suds drip off my arms, then down the drain. I entered the OR, gowned up, and draped the patient, making sure the corners were sharp and neat. I wanted this case to be perfect. I opened the skin of his lower back. He was an elderly man whose spine had degenerated, compressing his nerve roots and causing severe pain. The attending wandered in as I began to remove the lamina, the back wall of the vertebrae, whose bony overgrowths, along with ligaments beneath, were compressing the nerves.

"Looks good," he said. "If you want to go to today's conference, I can have the fellow come in and finish."

Completed the operation

My back was beginning to ache. Why hadn't I taken an extra dose of NSAids (non-steroidal anti-inflammatory drugs) beforehand? This case should be quick, though. I was almost there.

"Naw," I said. "I want to finish the case."

The attending scrubbed in, and together we completed the bony removal. He began to pick away at the ligaments, beneath which lay the dura, which contained spinal fluid and the nerve roots. The most common error at this stage is tearing a hole in the dura. I worked on the opposite side. Out of the corner of my eye, I saw near his instrument a flash of blue - the dura starting to peek through.

"Watch out!" I said, just as the mouth of his instrument bit into the dura. Clear spinal fluid began to fill the wound. I hadn't had a leak in one of my cases in more than a year. Repairing it would take another hour.

"Get the micro set out," I said. "We have a leak."

By the time we finished the repair and removed the compressive soft tissue, my shoulders burned. The attending broke scrub, offered his apologies and said his thanks, and left me to close.

As we uncovered the patient, the scrub nurse, one with whom I hadn't worked before, said, "You on call this weekend, Doc?"

"Nope." And possibly never again.

"Got any more cases today?" "Nope." And possibly never again.

"Shit, well, I guess that means this is a happy ending! Work's done. I like happy endings, don't you, Doc?"

"Yeah. Yeah, I like happy endings."

I left the OR shortly after, then gathered my things, which had accumulated over seven years of work - extra sets of clothes for the nights you don't leave, toothbrushes, bars of soap, phone chargers, snacks, my skull model and collection of neurosurgery books, and so on.

Left books behind

On second thought, I left my books behind. They'd be of more use here.

Tears welled up as I sat in the car, turned the key, and slowly pulled out into the street. I drove home, walked through the front door, hung up my white coat, and took off my ID badge. I pulled the battery out of my pager. I peeled off my scrubs and took a long shower.

Later that night, I called (my co-resident) Victoria and told her I wouldn't be in on Monday, or possibly ever again, and wouldn't be setting the OR schedule.

"You know, I've been having this recurring nightmare that this day was coming," she said. "I don't know how you did this for so long."

From the book When Breath Becomes Air by Paul Kalanithi. Copyright © by Corcovado, Inc. Reprinted by arrangement with Random House, an imprint of Random House, a division of Penguin Random House, Inc. All rights reserved.


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