For readers of Henry Marsh's Do No Harm, Paul A. Ruggieri's Confessions of a Surgeon, and Atul Gawande's Better, a pioneering surgeon shares memories from a life in one of surgery’s most demanding fields
The 1980s marked a revolution in the field of organ transplants, and Bud Shaw, M.D., who studied under Tom Starzl in Pittsburgh, was on the front lines. Now retired from active practice, Dr. Shaw relays gripping moments of anguish and elation, frustration and reward, despair and hope in his struggle to save patients. He reveals harshly intimate moments of his medical career: telling a patient's husband that his wife has died during surgery; struggling to complete a twenty-hour operation as mental and physical exhaustion inch closer and closer; and flying to retrieve a donor organ while the patient waits in the operating room. Within these more emotionally charged vignettes are quieter ones, too, like growing up in rural Ohio, and being awakened late at night by footsteps in the hall as his father, also a surgeon, slipped out of the house to attend to a patient in the ER.
In the tradition of Mary Roach, Jerome Groopman, Eric Topol, and Atul Gawande, Last Night in the OR is an exhilarating, fast-paced, and beautifully written memoir, one that will captivate readers with its courage, intimacy, and honesty.
|Publisher:||Penguin Publishing Group|
|Product dimensions:||5.30(w) x 8.10(h) x 0.60(d)|
|Age Range:||18 Years|
About the Author
Bud Shaw grew up the oldest child of a general surgeon in rural south central Ohio. He graduated with an AB in Chemistry from Kenyon College in 1972 and received his MD degree from Case Western Reserve University School of Medicine in 1976. In 1981, he completed a surgery residency at the University of Utah, then trained in Pittsburgh under Tom Starzl, the father of liver transplantation. An internationally renowned transplant surgeon by age 35, Shaw left Pittsburgh in 1985 to start a new transplant program in Nebraska that quickly became one of the most respected transplant centers in the world. An author of 300 journal articles, 50 book chapters, and a founding editor of the prestigious journal, Liver Transplantation, he retired from active practice and the department chairmanship in 2009, and now focuses on writing, teaching and the value of narrative studies in medical education and clinical practice. His prize-winning essay, My Night With Ellen Hutchinson, published in Creative Nonfiction Magazine, was nominated for a 2013 Pushcart Prize and received Special Mention. The father of three adult children, Shaw lives with his wife, novelist Rebecca Rotert (Shaw) in the wooded hills north of Omaha, Nebraska.
Read an Excerpt
Photo by Rebecca Shaw
We can’t know, let alone remember all the people whose presence shapes what we become. At least I can’t, and that’s my excuse for failing to recognize all of those I’ll now leave out, from the teachers who wouldn’t let me get away with mediocrity and the guys who plucked my nineteen-year-old hitchhiking self from the freeway one frigid midnight and spent the next eighty miles trying to convince me to become gay, to the few teachers who worked so diligently at making students feel small and useless and the many more whose patience and faith often felt undeserved yet no less inspiring. They all played a role. That said, I want to recognize a few, not necessarily because they are most important, but because of their persistence.
When I was six years old, my mother made writing stories a work of joy and pride. I discovered an alternate world, one in which I had complete control. Her untimely death changed all worlds forever, infusing a reality I spent decades denying, no matter how real it became. My father taught me to be my own worst critic, from a similarly early age, less with his words than with the intangible signs of his joy and disappointment. He was also my hero, in so many wonderful ways. I miss him horribly.
Until Mr. Leonard Gwizdowski gave me my first C grade in fifth grade, I’d never received less than an A on anything. My mother was outraged with him, but Gwizzy stood his ground and I had to learn to study—really study. Six years later, Mrs. Mildred Veler gave me a required reading list separate from the other students’. “You’re lazy,” she said, and told me to start with Joyce. At Kenyon College, William Klein called my freshman prose verbose and obtuse, Galbraith Crump brought Shakespeare to life, Perry Lenz left America’s great literary heritage deeply imprinted on my soul, and John Ward showed me unexpected joy in Smollett, Defoe, Bronte, Austen, Richardson, and Thackeray.
In Utah, so many surgeons proved critical to my training, including fellow residents, faculty, and dozens of private surgeons. I’m compelled to thank Frank Moody for setting such an annoyingly high standard for all of us and for always pushing me to be my best, despite my resistance. Gary Maxwell did more to lead me into transplantation than anyone. He inspired me with both his compassion and his astonishing abilities.
At Pittsburgh, I learned kidney transplantation from Tom Hakala, Tom Rosenthal, and Rod Taylor. I witnessed the unflinching integrity of Hank Bahnson, the unbreakable loyalty of Shun Iwatsuki, and the unstoppable drive of Tom Starzl. I owe more than I can ever express to Shun for being there to save my sorry ass over and over, and to Tom for being the font from which so many of my opportunities flowed.
In 1985, Bob Baker, Charlie Andrews, Bob Waldman, and, most important, Mike Sorrell and Bing Rikkers put together a proposal that pulled Bob Duckworth, Laurie Williams, Pat Wood, and me from Pittsburgh to Omaha, Nebraska. Together with Joe Anderson, Jim Chapin, Barb Hurlbert, Rod Markin, and Reed Peters, we forever changed the University of Nebraska Medical Center. My appreciation of the risks these people all accepted to make our work such a huge success is undying. Their expertise and dedication were indispensable.
I have many friends who read my earlier work and encouraged me to keep trying, including Jamie and Kyle, Carlos and Kathy, Bill and Chris, Steve and Genni, Mike Duff, and especially Dirk and Cath, whose friendship and faith are unflinching.
This book would never have come to life without the reboot I got from Steve Langan and the many participants in his Seven Doctors Project, the stubborn faith and encouragement of Amy Grace Loyd, and Jonis Agee’s willingness to introduce me to Noah Ballard, who as my agent has brought wonders to my life. The confident enthusiasm that he and Matthew Daddona, the world’s most gently tenacious editor, have brought to this work both astounds and delights me. Bo Caldwell and Ron Hansen unwittingly inspire me, most especially with their grace in success. Lee Gutkind introduced me to creative nonfiction during many sleepless nights together in Pittsburgh; his guidance has been invaluable.
My brother, Steve, and sisters, Mindy and Beth, may not agree with my versions of the events of our lives upon which I’ve shone so much wattage, but obviously my memory is better than theirs. I apologize for repetitively nagging them for details none of us see so clearly anymore, and I thank them for allowing me this indulgence.
I adored Carol for her art, her spirit, and her courage in facing death. I love Chris for our twenty-five years together, for our three children, and for loving me still. Ryan, Nat, and Joe are my real reason for existence, more for the joy they individually bring to the world than for notions of propagation.
Most of all, I thank Rebecca for resurrecting me, for nurturing my art, for keeping me honest, and for trusting me with her unfathomable love. I will always dance with you.
This is not a work of fiction. The events I have written about happened. That said, I must admit that in re-creating them, I have had to rely mostly on memory, not only mine but also that of many other people who were present or aware of what occurred. I was regularly surprised by how often my most indelible memories were not those of others. This sometimes led us to intense debate, and if we failed to resolve our confusion, I almost always stuck with my version because it felt most faithful to my experience.
Many of the stories involve patients. To protect their identities, I have changed or left out names, dates, places, and other details that are considered protected health information. These stories are thus merely representative of real experiences rather than the experiences of individual patients. I also found relevant aspects of some patients’ stories in public records, including newspaper and television archives, obituaries, court records, and social media sites.
I was a transplant surgeon and most of my patients were recipients of liver transplants. Their stories are sacred. Their wait for a donor on the one hand and the heroism of organ donation on the other remain the most compelling part of the transplant story. I, almost as much as our patients, owe everything to the donors; more specifically, to their survivors who gave consent for donation. Without those acts of grace and courage, none of the patients I met would have survived, and I would never have experienced the joy and despair of trying to save them. Like many professionals who care for these patients, I lived every day of my clinical career with the horrible reality that more than half the people awaiting organs will never get them. We all long for the day when that is no longer true.
I was desperate to show how good I was that night. The patient was Max Stinson, a liver surgeon from Texas who, ironically, had a congenital form of liver disease that had finally progressed to liver failure. He was already opened up on the operating table when we got back from Virginia with the donor liver. Shun Iwatsuki was scrubbed in and had half a dozen other people helping him. Most of them left when we scrubbed in, but Shun stayed.
Dr. Starzl wasn’t happy. Shun stood across from him. He had worked with Starzl in Denver and in the course of time, no one would be more important to my training. Dr. Hong from Shanghai stood to Starzl’s right. His job was to retract the rib cage out of Starzl’s way. He held on to the upper wound with both hands and leaned back like a water-skier. I would soon learn they called him the Human Retractor. Carlos Fernandez-Bueno was in his second year of training. He, too, had come from Denver, but by fall he would leave to accept a job he couldn’t refuse at a prestigious East Coast center.
Starzl immediately began complaining. Shun kept silent and moved like a cat to retract something one way, push something else another, and, without a word, get Hong or Carlos to do something useful. I thought them telepathic, and this was their desperate attempt to appease the angry alpha. Already I doubted my own survival, useless as I was in this new world.
Shun’s incision was shaped like the arms of a flattened Mercedes hood ornament, with a short vertical line coming downward from the base of the sternum to join a broad inverted V that stretched from one side of the abdomen to the other. Except for the donor in Virginia earlier that night, I’d never seen a body split so widely before.
I caught a glimpse of the liver lurking under the diaphragm. It was a shriveled, knobby, greenish-yellow lump. It was much too small for the space around it and it sloshed around in a puddle of blood every time the ventilator fired and pushed the diaphragm down.
Blood seemed to be coming from everywhere. The skin of the abdomen below the incision was a translucent, muddy yellow and coursed with giant blue veins running outward from the navel. I could see that the incision transected the course of some of these vessels, and when Starzl started removing sponges from around the edges, those veins rivered dark and red.
Starzl worked furiously to stop the bleeding. He lashed the open veins with silk sutures, grabbing needle holder after needle holder from the scrub tech as Carlos, then Hong, then Shun grabbed the ends and tied them down snug. I grabbed one when I saw my chance and broke it on the second throw.
“Shit,” Starzl said and threw another stitch where I’d broken mine. This time I pulled too hard and the silk pulled out of the tissue and a blood torrent erupted. Carlos grabbed a sponge and pressed down, then got out of the way just as Starzl threw another stitch and tied it himself. He threw two more in the same spot, Carlos tied one and Shun the other, and finally the bleeding stopped. Shun frowned at me and vaguely shook his head.
I decided I could cut the ends of the stitches after they tied them. It was a job we gave to medical students. I was a trained surgeon, and a good one by all accounts back in Utah, where I’d finished my training less than a month earlier. So I grabbed a pair of scissors and cut the suture.
“Too short, goddammit,” Starzl said. “That’ll come loose and he’ll bleed to death. Is that what you want?”
He laid down another stitch and Shun tied it, four throws, and I cut it.
“That’s too long,” Starzl whined. “Come on, now, Shun. Help me. He doesn’t know what he’s doing.”
• • •
I worked my last day as a surgery resident at the University of Utah on June 30, 1981. I was thirty-one years old and I wanted to be a transplant surgeon. Dr. Thomas E. Starzl, the father of liver transplantation and perhaps the most renowned transplant surgeon in the world, had granted me a position to train with his team. He had moved his transplant program to Pittsburgh only six months earlier. I’d grown up in Ohio but I’d never been to Pittsburgh. I hated their football team, the Steelers, because they always beat my beloved Cleveland Browns.
My wife and I sold her car, gave the pickup truck to a friend, loaded my car and everything else into a rented truck, and headed for Ohio before dawn on Saturday, July 4. Eight miles east of Point of Rocks, Wyoming, we hit an antelope yearling just as the sun rose above the rocks and sage. In Omaha we drove through smoke from a grass fire started by fireworks. In Ohio we unloaded the truck into my father’s garage. I turned in the rental on Monday and called Starzl’s Pittsburgh office the next day to ask advice about where to find a place to live.
I had arranged to take the month of July off. I figured five years of surgery residency and the specter of a two-year fellowship in transplant surgery justified it. We’d get a place to live and move in and I’d have nearly three weeks to do whatever I wanted. It would be like summer vacation when I was twelve.
The secretary in Starzl’s office put me on hold. She said I needed to talk to someone else.
A female voice with a strange twang I’d later recognize as Pittsburghese came on. “Dr. Shaw? Where the hell are you?”
I said I was in Ohio, at my father’s house.
“You were supposed to be here last week,” she said. “July first, you know?”
She didn’t understand. I’d talked to someone in March. A woman, I said. She promised to tell Dr. Starzl. I wasn’t supposed to start until August.
I looked at the calendar on the wall above the phone in my dad’s kitchen. “Saturday,” I said. “August first.”
“We don’t have any information about that, Dr. Shaw,” she said. “Dr. Starzl expected you last week. You’ve already missed two nights of call. I suggest you get your butt here today, tomorrow at the latest.”
That was Tuesday morning. By Thursday night, we’d driven to Pittsburgh, put money down on a house a few blocks from the hospital, moved what we could with my dad’s pickup, and found a grocery store open after ten p.m. I made my way to the hospital Friday morning and that evening my wife called to say the refrigerator had died. On Saturday I was on call when someone broke the window out of my car on the hill above the football stadium. They stole my toolbox and a Utah Jazz coffee mug. Sandee told me she wouldn’t have parked up there.
Sandee was a nurse on the transplant team. She led me around the hospital my first day and told me where not to park on my second. When we went to the adult intensive care unit, a young woman in a short white coat and a shiny new stethoscope draped around her neck asked me to sign a petition banning liver transplants.
“They’re unethical,” she explained.
I wanted to laugh but she was so earnest. I said I was the new transplant fellow.
“Oh,” she said. “Then you should definitely sign it.”
She told me that in its first six months, the new transplant team had done six liver transplants and all six patients were dead.
“One time they ran out of blood across the whole state of Pennsylvania,” she said. “Shut down surgery everywhere for days. It was awful. Gruesome, actually.”
Sandee said the young woman was exaggerating. The blood shortage thing only happened one time; it was only in Allegheny County and only for part of a day.
“And the kids are all doing great,” she said.
“The kids?” I said.
“All six of them,” Sandee said. “Alive and well.”
“Oh, so then you’re batting five hundred?” The medical student stood with her head cocked, her clipboard resting on her hip.
“This ain’t baseball, sweetie,” Sandee said. She grabbed my arm and pulled me away and through the automatic door into the hall.
The University of Pittsburgh didn’t have any place to put Starzl and his team when they arrived six months earlier, so they parked him in an unused laboratory, a huge room cleaved by long lab benches, complete with working sinks and gas jets. I shared a desk with the other transplant fellow. It was against the wall between two benches and the phone lines ran overhead, held to ceiling tile frames with bread-bag twist ties. Sandee said it was temporary.
“For how long?” I asked.
“Well, for at least the past seven months,” she said.
I thought about the petition and wondered where we’d be in another seven months.
In my first meeting with Dr. Starzl I was asked about Dr. Moody. Moody was the chairman at Utah, where I’d trained. He had convinced me I should train with Starzl and he’d apparently written a flattering letter of recommendation.
“Frank Moody said you’re a pretty good surgeon,” Starzl said. “Do you think that’s true?”
He looked at me and I saw something in his eyes that made me nervous. His question felt like a test.
“I guess so,” I said. I felt like a thirteen-year-old. Then I told him I didn’t expect to do liver transplants. It felt like a confession.
“Why not?” he asked.
I said I was interested in kidneys and pancreases.
“I see,” he said. An odd frown came over his face, the space between his eyebrows pinching together. He turned in his chair, placed his hands on his knees, and sat for a moment looking at the wall; I could see the gentle slope of his shoulders and flawless profile of his nose. Then he stood up.
“Well, let’s see,” he said. He seemed uncertain what to say next as he looked almost furtively at the floor, then at me, then away.
I said I’d better be going and he smiled and held out his hand and we shook.
“Good to meet you, then,” he said.
I nodded and left.
I’m not sure how I expected him to respond when I said I had no ambition to do liver transplants. I don’t think I was seeking reassurance. Even now, I wonder if he thought I simply shared the mainstream judgment that liver transplantation was fruitless folly. When they learned of my decision to train under Starzl, some of the faculty in Utah and most of my friends thought I was making a huge mistake. One of the senior surgeons at a private hospital, a Mormon who’d been a transplant surgeon in New York, told me that liver transplantation was “just an expensive way to torture hopeless people before they die.”
I wanted to laugh at them, call their skepticism ignorance, but I couldn’t escape the doubts that still nagged me. Everything I knew about Starzl and liver transplantation was founded on years of rumored disasters coming out of his program in Colorado. By the time I had to decide where to seek training in organ transplant surgery, it seemed to me that things had changed. Starzl’s group had already begun working with a new drug that was much better at keeping the organ recipient’s immune system from attacking the transplanted organ. It was called cyclosporine A, it promised to revolutionize the field, and Starzl was the only surgeon in the United States with access to it for use in patients getting either kidney or liver transplants. And then there was Frank Moody. Frank told me I needed to think big, that I should work and train with the best. Dr. Moody made me feel like going anywhere else would be a sellout, that working on the real frontier of transplantation was a far more glorious pursuit than playing it safe behind the front lines of that war.
• • •
“Come on now, take this!” Dr. Starzl had placed a retractor over the bowel.
Shun slapped my hand to get my attention and I grabbed the handle and held it exactly where he’d put it.
“Not like that,” Starzl said. He ripped it out of my hand and repositioned it. “Like this.”
I took it again and concentrated on not moving a twitch. I looked around the room and found it still so incomprehensible. In my prior experience, operations mostly involved a surgeon and a couple of assistants. Everyone knew who was in charge, who set the course, who was the decider. Starzl had five of us scrubbed in with him that night. The only other time I’d seen so many surgeons working on one case involved two people connected at the tops of their heads. It was in Utah and I was the resident on the plastic surgery team, and somehow I’d gotten a place there among the neurosurgeons and pediatric surgeons trying to separate these conjoined twins. It was, in my wide-eyed view, a clusterfuck. Every senior surgeon had an opinion about everything and I felt like a plaintiff’s witness. I guess the difference with Starzl was that everyone knew that he, and only he, was in charge. My only role in his operating room was to stay out of everyone’s way, particularly his, and I kept screwing that up.
Hong stood on a platform in order to be high enough, leaving about eighteen inches of space between him and Dr. Starzl. That was my space. Sometimes I’d try to help and lean in just a little and I’d bump Starzl’s arm or his shoulder and he’d give me a hip check or an elbow to the chest. I didn’t think it was intentional. Protecting his space was instinctual.
That first night, I couldn’t yet see the pattern in anything we did. Often, Starzl just grabbed whatever hand was close by and shoved it where he wanted it, with no apparent regard for whose hand it was or what else it ought to do. “Shitfuckgoddamn,” he’d hiss. “I can’t see.” “Don’t hinder me, help me,” he’d say when someone tried to help and failed. This was my initiation to the operating room of Dr. Thomas Starzl, and although I didn’t know it at the time, these were but a few of the phrases I would learn to hate and mock and, in the distance of time and place, yearn to hear again.
The Pros from Dover Fly to Virginia
Earlier on that day when I met Dr. Stinson in the operating room, we were making rounds on the tenth floor with Shun when suddenly he stopped talking.
“Uh,” he grunted. “Boss coming.”
I turned and saw Dr. Starzl coming toward us down the long hallway. He looked energized. His steps were quick, with a bounce that suggested he wasn’t so much in a hurry as he was excited. He was a thin, athletic man and looked much younger than his fifty-five years. An entourage trailed him. Two or three were Asian. They wore lab coats with sleeves rolled up to their wrists, the wide shoulders sagging toward their elbows and hems bouncing against their shins. Another was a tall, graying man in a tailored suit. He walked just behind Dr. Starzl and ahead of the Asians. He was someone important, but I’d never know his name. A young woman with red hair and a constant smile walked at Starzl’s side, clutching a manila folder to her chest. As they came closer I saw Starzl had a lit cigarette pinched between his thumb and index finger. He carried it so that his hand sheltered the ember from the wind of his gait.
Shun seemed to know something. Starzl looked up briefly, their eyes met, and Shun nodded and took a deep breath. I’d only just met Shun. I hadn’t figured out who he was yet.
“Well, let’s see,” Starzl said. “We’ve got an organ for Dr. Stinson.”
I was among a group of surgery residents and nurses making rounds with Carlos and Shun. Starzl glanced quickly at us. His head movements were jerky, as though he were stealing a look and didn’t want us to notice.
“Tonight?” Shun said.
Starzl looked down at his cigarette, then tucked his head under his shoulder and took a drag and blew it out quickly. We watched in silence.
“Well, let’s see, then,” he said.
He looked at Shun again, almost as though he’d been thinking about it; he looked at me and his frown vanished and he seemed to nod at me, almost nervously. I looked behind me to see if I’d been mistaken.
“Yes, of course tonight,” he said. “Helicopter’s picking us up . . . when?” He turned to the woman with the folder and bright red hair.
She looked at her watch. “Forty-five minutes,” she said.
“It’s a perfect liver,” he said. “I need a first-class team, so let’s see. . . .”
He looked us over and I tried to make eye contact.
“We can take . . . how many?”
“In addition to you and me?” she said. “Four.”
“Right,” he said.
Suddenly he jumped and dropped his cigarette to the floor, then looked at his palm. “Shitfuckgoddamn,” he said and shook his hand. He crushed the cigarette out against the linoleum with the toe of his white Reebok.
“So, let’s see. . . .”
He looked us over again and pointed to Carlos, the other transplant surgery fellow. “You,” he said. Then he pointed to two of the Asians, a stocky, balding man and a young woman with hair to the collar of her white coat. “Hong and Wu?” he said and they both nodded. He looked at me and started to point but then stopped. “Well, I’d take you but you aren’t interested in livers.”
I protested. “That wasn’t what I meant,” I said. “What I meant was—”
“So you are interested.”
“Yes,” I said. “Very much.”
“Well, all right. That’s different,” he said. He looked at Shun. “We’ll call when we land.”
He turned and bumped into the tall man in the suit, mumbled something, and walked off. The others hurried after him, except for the woman with the folder.
She told Carlos to be in the ER in twenty minutes. She looked at me and stuck out her hand. “I’m Mary Ann,” she said. “You must be the new fellow.”
I said I was.
“Twenty minutes,” she said and walked after the team.
We’d fly at night, low and fast in a helicopter over cities and farms and the Allegheny Mountains. I was hoping to snag a seat up front.
A van took the five of us to the top of the hill behind the football stadium, where the helicopter waited. Dr. Starzl carried a wadded bright blue sleeping bag. He went to step into the helicopter and tripped over the end dragging along in the grass. The blades had begun to cross over our heads and a whistling came from the turbines when he reeled the bag in and pushed his way into the cabin. He and his blue bag sprawled across the back bench and Hong and Wu slid into the rear-facing bench and sat staring at him. He reached into a pocket in his cargo pants and pulled out an eye mask. He noticed Hong.
“Purloined from your airline,” he said, grinning. “Air China.”
Carlos was a big man and he hesitated before climbing past Starzl and wedging into the corner of the bench. Mary Ann climbed in on the other side of Starzl and I saw that there were no more seats. Elated, I turned toward the front door and bumped into a man wearing headphones coming out.
“We can only take five,” he yelled.
Mary Ann looked at Dr. Starzl. He’d covered his head with the bag and seemed to be leaning against Carlos. She told Hong to stay behind.
Dr. Hong began to blink.
“Hong,” she said and smiled at him, taking care to mouth her words slowly, in distinct syllables. “You. Need. To. Get. Out.”
Dr. Wu was closest to the door; she got up, jumped out of the helicopter, and walked away from us without looking back. As I took her place, I looked after her and noticed the van was already gone. The copilot checked our seat belts and started to pull open the sleeping bag to check Starzl’s, when Mary Ann grabbed his hand and shook her head. He hesitated, then nodded and closed the door, locking us in. As we rose up from the practice field I could see Dr. Wu making her way in the dark down Robinson Road and past the place where they’d broken into my car and stolen my toolbox.
I couldn’t see much from my seat in the cabin. Hong had the window and he leaned his head against it and slept. We seemed always to be flying above a layer of broken clouds and without a moon. We landed on top of the large metropolitan hospital and walked down a flight of stairs and into an elevator.
I suppose it was all so glamorous—the helicopter arrival, the armed-guard escort to the locker room, the Trapper-John-in-Japan arrogance when we walked into the operating room like the pros from Dover—but I was too distracted to enjoy it. Or anxious; mostly I worried about being disliked for our hubris.
What unfolded over the next several hours was startling. I realize only now that in all those summers in the operating room with my dad, with other surgeons during my medical school rotations, and in five years as a resident working with surgeons in four private hospitals, a VA medical center, and a progressive university hospital, I’d never felt so much chaos or seen such licking aggression between two surgeons.
The encounter in Virginia was the first for the chief of surgery with Starzl and his team. In those days, before we published a paper proving otherwise, the running rumor among kidney transplant surgeons said that when taking out a liver, the Pittsburgh team damaged the donor kidneys. Maybe more challenging, surgeons, especially transplant surgeons of the era, considered the operating room their personal domain. They weren’t accustomed to coordinating what goes on in there with other teams led by other alpha males.
Starzl understood all that. He knew he had to cultivate these relationships if he expected to get any donor livers from outside the Pittsburgh fiefdom. He tried to be affable, to make sure things went smoothly, but he also knew he had little margin for error in taking a liver. Maybe a kidney recipient could go back on dialysis if the new kidney didn’t work, but people with failing livers had no such option.
Having a donor provide a liver or heart instead of just kidneys was a newsworthy event in those early days, one that brought out TV station and newspaper reporters to interview us on many of our donor runs. In Augusta, Georgia, later that year, three police cruisers met us at the airport and we drove 120 miles per hour to the hospital with trailing TV trucks unable to keep pace. In Cape Girardeau, Missouri, off-duty nurses brought in boiled shrimp, fried chicken, and snickerdoodles in case we were hungry, and in Dayton, Ohio, the mayor stopped by for a photo op. We were, after all, the pros from Dover.
The chief was helping the resident do the case and Starzl had little patience for the pace. Once gowned and gloved, we pushed our way up to the operating table, the resident backing away, still holding his forceps and scissors.
“You’ve done a fabulous job here,” Starzl said. “Terrific, really. Mind if I do a little work up here?”
Hong tried to worm his way up to the other side of the table but the chief was an immovable green iceberg, so Hong stood back with his hands held close in front of him and rocked from one foot to the other. Carlos got in next to the chief and I stood back near the head of the table and waited for instructions. I could see the donor’s neck and face and I realized he and I were about the same age.
The anesthesiologist saw me looking and arched his eyebrows. I moved closer to him on his stool and bent down.
“How’d he die?” I whispered.
“Fell out a second-story window,” he said.
“Celebrating his promotion to manager.”
I nodded and backed away.
Dr. Starzl pulled back the drapes to expose the chest. “Shit,” he said. “We’ll need to prep this.”
The chief suggested we hold off for a while. “Twenty, thirty more minutes, Tom,” he said. “So Anthony and I can get the kidneys ready.”
The chief motioned for the resident to come back to the table and I moved out of the way to let him in.
Starzl asked the scrub tech for Betadine, the iodinated stuff we use to sterilize the skin before surgery, and he painted the chest and upper abdomen with an energy that scattered brown splotches over Hong’s mask and gown, his eyelashes and neck.
“You go ahead down there,” Starzl said. “We’ll just do a little work here so we don’t hold you up.”
Starzl took a knife and extended the chief’s midline abdominal incision all the way to the sternal notch, at the base of the neck. Then Carlos took a large hook knife and a hammer and split the sternum from top to bottom, while Hong and I tried to stay out of everyone’s way. They put in the retractors to open the sternum wide and suddenly there was the dead man’s heart jumping up and down in time with the beeping monitor, and just below it, the liver glistening and pink and more exposed than I’d ever seen it before. Starzl got Hong into his waterskiing position on one side of the rib cage and had me pull on the other while Carlos and he began moving the guts out of the way so they could get to the liver’s blood vessels.
I could see this wasn’t going to make the chief happy. Starzl needed the guts pushed downward toward the feet, and the chief needed them moved up toward the liver to allow him to see the kidneys and the lower part of the aorta and the vena cava.
“Why don’t you take a short break now, Tom?”
“You’ve done a terrific job there . . . Tony, right?”
“Anthony,” the resident said.
“Well, Anthony, you’ll make a great surgeon someday.”
“Seriously, Tom, give us thirty minutes and we’ll be out of your way.”
“Just let me get a look down here, make sure we haven’t got unusual anatomy. A few minutes more, that’s all.”
I saw my chance to help and put a sponge on top of the stomach to pull it aside.
“Shit, now, help me, don’t hinder me. Carlos, for God’s sake, show him what to do. He doesn’t know what he’s doing.”
He was talking about me, of course.
We left two hours later with what Starzl said was a perfect liver. The chief and Anthony were still working on getting the kidneys out when I took off my gown.
“Nice to meet you all,” I said. I’m not sure they heard me.
Max Stinson Gets a New Liver
After what seemed like hundreds of sutures, the bleeding inside Dr. Stinson came under control. I felt suddenly exhausted. It was two or three in the morning by then and I was desperate to be of some use and barely able to stay awake, and then Starzl started working on the ruined liver. Every millimeter of progress took an eternity. We had to stitch and tie everything. I was thinking I’d have taken the electrocautery and just burned most of that tissue, been done with it. Then one of the ties came off and bleeding erupted and I thought maybe these veins were bigger prey than cautery could handle.
This was different surgery, different from anything I’d been trained to do. These people seemed to have lots of rules, even about things I took for granted. Like rules for tying off blood vessels before cutting them. Always four knots, not three. Always either 4-0 (thinner) or 2-0 (thicker) sizes of ties, never 3-0 (in between). Asking for 3-0 broke the rules. Not only did a request for 3-0 indicate indecision; it was also plain wrong. I was stupid for not knowing that the job of the moment required either 4-0 or 2-0 and not something in between. Mama Bear’s choices made me a stupid surgeon. And they had rules for instruments. Only certain clamps were correct. Hand Dr. Starzl a hemostat with a subtle difference in shape from the one he wanted and you would break the rules. The wrong clamp went to the floor, or with a terrible clang into a stainless steel kick bucket.
Learning the rules was easy. That stuff never changed. But learning the complex steps of the operation felt impossible. I was anxious to be the best assistant Dr. Starzl had ever had, but just when I thought I had it figured out, he did something different. Sometimes it resulted in astonishing maneuvers and I felt lucky to witness his creativity. Too often it seemed like a distraction. I began to be suspicious. I thought that aside from the trailblazing gig, he also hated being predictable.
I had never seen anyone work on a liver so knobby and shrunken. The surgeons who had taught me always avoided working above and behind the liver, as though it were a no-man’s-land where only trouble lay. Starzl destroyed that myth. It reminded me of the video of a Korean psychic surgeon on 60 Minutes, the one in which the guy shoves his hand right through the patient’s clothes and skin and swirls it around inside while making weird sounds and suddenly pulls his hand out holding a wriggling, ugly thing. Pure magic, just like the way Starzl freed up this horrible-looking wart of a liver and had it ready to remove before I even knew what he was doing.
Shun said something to Carlos and Carlos left the table. I thought he was taking a break but a few minutes later a sharp bang made me jump and I saw Carlos behind the back table beating on a towel with a steel mallet. He unfolded it and inside was a shattered plastic bag and a pile of crushed ice. He poured the ice into a steel basin, grabbed another bag of frozen IV fluid, wrapped it in a blue towel, and started banging away. And there was Mary Ann. She pushed a plastic spout into the end of a bag of liquid and began streaming it into the basin with the ice.
“Call Mary Ann,” Starzl said. “We need the liver.”
“I’m right here, Tom.” Mary Ann lifted the Playmate cooler onto a stand and opened it up. She cut the strings with a scalpel blade and opened the first two bags and Carlos reached in and took the third. He laid it in the basin of slush and opened it.
“Oh,” Starzl said after a few minutes. He looked up and saw Carlos inspecting the new liver. “Good,” he said.
When we took the liver out of the belly of the donor earlier that night, I saw the vast emptiness left behind and felt awed but unconcerned. The donor was dead. It was a cadaver. I’d seen lots of things removed from cadavers in the lab or the morgue. That’s how we learned anatomy all those years ago.
When Tom Starzl took the liver out of Dr. Stinson, he lifted it out by the clamp he’d put across the vena cava, like pulling a goblin’s head out by the neck. He dropped it dripping black into a basin. I watched Shun hand it off to the tech, who laid it on the back table. I looked at the empty grotto where the liver had once lived and saw nothing but an impossible situation. I had a hard time comprehending that we were going to fix this horrendous problem, this unimaginable absence.
When Starzl called for the new liver, Carlos brought it up in a bag of icy water and Tom reached in, hauled it out like a tuna, and laid it on a towel. Fog rolled off the pale, glistening surface and Shun held it between his hands so that the opening of the vena cava at the top was exposed. Starzl put in some stay sutures, then lowered the liver into place while Shun and Carlos pulled up on the stays.
“Go, for God’s sake,” Starzl said. He tied the stay suture on his side and Shun tied his.
And then he sewed the new liver in and I couldn’t believe what I was watching. I’ve done it myself a thousand times since then, but that night it struck me as the pinnacle of surgery, connecting all of these blood vessels and racing against time because once out of the ice, the liver was gradually warming up and we had to get the blood flowing to it in less than forty minutes. I tried to help by cutting the last suture, the one for the portal vein, but I fucked it up instead and cut it too short and the whole thing unraveled and Starzl had to do that vessel all over again and Jesus fucking Christ didn’t Frank Moody teach me anything during those five years in Utah? Shun shook his head at me, squinted, and grumbled a warning every time I started to move. I felt my legs begin to shake, but all I could do was breathe more slowly and hope I didn’t pass out. Then the suturing was done and Shun looked over the top of his glasses at the anesthesiologist.
“Are you ready?” Shun said.
The anesthesiologist jumped to his feet and turned up the flow rates of the intravenous fluids, his eyes darting back and forth over the various tracings on his monitor.
“Yes,” he said. “I think we’re ready.”
“Come on, now,” Starzl said. “Pay attention. You must be certain!”
Starzl reached up over the top of the liver, pulled it down with his left hand, and grabbed the big clamp on the upper vena cava with his right.
“OK?” he said.
What People are Saying About This
This is just about the best book about surgery and a surgeon I have ever readby surgeon or civilian alike. It is warm, honest, straightforward, sad, amusing and compelling from beginning to end. --Lee Gutkind