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One Children's Place
Inside a Children's Hospital
By Lee Gutkind
OPEN ROAD INTEGRATED MEDIACopyright © 1990 Lee Gutkind
All rights reserved.
Marc Rowe, chief of Surgical Services at Children's Hospital of Pittsburgh, returned home from Boston, where he had been helping to conduct the surgical certification boards for the American Board of Surgery, at about 9:00 P.M. He sprawled on the sofa in his family room and watched two movies on television, periodically participating in a sporadic conversation with his wife. Although he was not on call that evening, he fully expected to be summoned back to the hospital, so he was on edge, unable to halt the galloping adrenaline—that sense of crisis and immediacy that had been with him throughout his surgical life. But as the hours passed, he began to doze, although it was always difficult to sleep soundly when he suspected, from years of experience, that the telephone would ring, that the voice on the other end would tell him about one of his patients who had taken a bad turn, or a Level I trauma—a critically injured child—who needed help. But tonight he was spared the interruption, and he slept for a few hours before waking, dressing quickly, and driving to the hospital through the foggy dawn.
The men's locker room at Children's Hospital is a shadowed and cramped space with lines of hard wooden benches squeezed between rows of metal lockers. There is a small lounge at the far end of the locker room, off a corridor that leads to the operating suite, and as he undressed, Rowe heard voices coming from that lounge, voices he recognized but did not particularly want to hear at that moment. He pulled on sweat pants, a sweatshirt, and a fairly new pair of running shoes and left the locker room quickly, taking the elevator from 7 down to G, padding softly past the information desk, and breaking out onto Fifth Avenue in a plodding jog.
"Watch, watch, watch your back!" yells a nurse, as a young resident, masked and in surgical scrubs, arms folded at his chest, backs into a tray of instruments spread out carefully on a blue towel.
Though he has only barely touched the tray with his sleeve, the resident, whose name is Joseph Collela, understands that he has contaminated all the instruments on it and that the entire setup must now be replaced. He rolls his eyes, mumbles an embarrassed apology, and takes a couple of steps sideways, trying to find a safe standing spot here in Operating Room 7 on the sixth level at Children's Hospital. He is waiting to assist the attending surgeon, Dr. Rowe, who has yet to arrive in the OR that early morning.
"We won't crucify you this time," says scrub nurse Suzanne Lomire, "but the next time ... watch out."
Nancy Van Balen, the circulating nurse, responsible for the preparation of instruments and equipment, as well as the source of all surgical supplies before andduring the procedure, quickly folds the contaminated instruments into the blue towel on which they were displayed and carries the entire package away. She then returns with another blue towel, folded similarly, which, with its corners unfolded, reveals a previously sterilized set of instruments, ready for use.
"She didn't like those tools anyway," says Sam Smith, a young and newly appointed attending surgeon, born and raised in Arkansas. "Attending" means that Smith is not only on staff at Children's but is also a faculty member, an assistant professor, in the Department of Surgery at the University of Pittsburgh, the institution with which Children's has long been the clinical pediatric affiliate. "Don't worry," he adds. "The first time I was in an operating room, I started picking up the instruments to see what they looked like. You can just imagine what those nurses did to me."
Smith, who had been a pediatric surgical fellow, training in Pittsburgh for the two years prior to his official appointment, had been replaced by Steve Teich, a balding, egg-shaped man of thirty-four, who has momentarily stepped away from the operating table to tape a surgical mask to the bridge of his nose so that it will not slip during the upcoming procedure. All the while, he continues to observe his patient carefully. The little girl has already been put to sleep but has not yet been completely prepared for surgery by the anesthesiologists milling around the table.
Although the name on the patient's chart, which sits on a shelf in a rear corner of the OR, is Chasity Danielle Burdette, her mother, Debbie, has explained that her first name is actually Chastity but the nurses in the tiny West Virginia hospital in which she was born registered the name on the birth certificate incorrectly. It hardly matters, however, for everyone calls her Danielle, "because that's what her father started to do as soon as she was born." Her father's name is Danny.
"Everyone" means not only Danielle's family, friends, and neighbors in St. Albans, West Virginia (population 12,404), but also the hundreds of other people—nurses, doctors, technicians, and administrators, not to mention the many other patients and families in the hospital—who have come into contact with the Burdettes over the years. Danielle and Debbie have lived most of the five years of Danielle's life at Children's Hospital and have come to exemplify the compassion that an institution, no matter how large, can offer families who are socioeconomically disadvantaged. Danielle suffers from Jeune's syndrome, a deformity in which the ribs are short and the chest wall is abnormally small, preventing any expansion of the developing lung.
The Burdettes are also representative of how the miracle and potential of modern medical technology can confuse reality and unmercifully conflict with the very system that makes the technology work. The fact that Danielle Burdette is alive today is the linchpin of the Burdettes' existence; the fact that Danielle could die today—and worse, that she could die any day thereafter, even if this and subsequent surgeries are wholly successful—is a fact that is too bitter for the Burdettes, or almost anyone else in this hospital, including her surgeons, to swallow.
"If we're going into her chest, will we need a bone saw?" Nancy Van Balen asks Teich.
"No, no bone saw," says Teich. He pauses, shakes his head, and indicates with his shoulders and eyes for Nancy to dab the perspiration from his forehead with a towel. "What we actually need is more heat. This is ridiculous," he adds.
"C'mon, Steve, you have to understand," says Suzanne Lomire, "I'm on a diet. This is how I lose my weight."
Keeping the operating room at approximately 80 degrees is actually a way of safeguarding against hypothermia, a real and constant threat in pediatrics, especially with infants and small children. The room thermostat is equipped with an emergency button that will provide an instant increase in heat, while Danielle's back is simultaneously being warmed by an electrically heated water mattress, which can also cool her down if she becomes overheated. Hanging above Danielle are also two "french fry lights" to further enhance her warmth.
"So jack it up some more, why don't you?" says Teich. "Couldn't we all afford to lose a couple of pounds?"
Usually, only one of Children's nine attending surgeons will scrub for each procedure, along with either a resident or a fellow. Often, since Children's is a teaching institution, if a fellow has scrubbed in, he or she will probably do the surgery, supervised by the attending. Except on rare occasions, residents, limited in experience, will do no more than follow suture lines (hold the long tail of the suture out of the way so that it doesn't obscure the area of the next stitch), tie knots, and generally help to expose the surgical field—no cutting. Because of the danger and the potential complications of Danielle's upcoming operation, Teich and Rowe will do the procedure together, with a second attending, Sam Smith, as an emergency backup in case of trouble, and Collela assisting.
"So Dr. Rowe was up in Boston yesterday playing God?" says Teich.
Unlike most specialties in the field of surgery, which has in general experienced a glut of personnel, pediatrics is a field in which surgeons have long monitored their own growth. Annually, there are in the entire United States only twenty or so pediatric surgical fellowships—the mandatory training position that a doctor must hold in order to be examined for certification by the American Board of Surgery. Although he works 80 to 90 hours a week at Children's, once his fellowship is completed and he passes his boards, an examination similar to, but even more intense than, the bar examination for attorneys, Teich will be virtually assured of a job. In fact, each week he receives an average of three letters inviting him to interview for available positions.
"When I took my surgical boards," says Smith, "it was the scariest day of my life. There you are, facing three hard-assed surgeons, grilling you for hours, who can blow you out of the water with a failing grade after you've dedicated seven years of your life to the field. They'll flunk you if you are late or if you go to the wrong room. I remember going to the room where my examination was scheduled and knocking on the door and no one answered. I knocked a second and a third time—and still no answer. Suddenly I thought I had somehow gone to the wrong room, that my career was over, just like that. Finally, the door opened and this guy was saying, 'Dr. Smith?'
"I said, 'Yes. Am I in the right place?'
"He said, 'Sure, but we were involved in a conversation and just got carried away. Sorry you had to wait.'
"I swear to God," said Smith, "waiting outside that door, I thought I was going to have a heart attack."
Smith dabs Danielle's abdominal area with Betadine and then begins to hook up a Foley catheter for draining urine output. The catheter will also demonstrate how efficiently Danielle's kidneys are functioning during the procedure, with units of fluid per hour computed and flashed on the monitor above the operating table. In addition to the Foley, a blue tube protrudes from her belly, a gastrostomy. "That's how she's fed," says Smith. "Danielle never liked to eat."
The anesthesiologists have also added a tangled mass of wires and alarms to her body. An intravenous (IV) tube has been placed in the vein of her right hand for the admission of blood and other fluids. An oximeter, a little instrument that makes her tiny thumb glow red, measures pulse rate and oxygen in the blood. There's an automatic blood pressure pump on her right arm that prints both systolic (when the heart is pumping) and diastolic (when the heart is relaxing) measurements on the monitor, along with a Broviac catheter, a more permanent type of entryway, or IV, for an influx of medications. Exiting from her mouth is an esophageal stethoscope plugged directly into the anesthesiologist's ear. "You never trust the alarms completely," says Smith. "We want to monitor her breathing continuously."
As he works, Smith tells me that he is very happy to meet a writer and that, in fact, there are many people at Children's interested in literature. "But we usually hide our books from one another. People in hospitals often don't share their private thoughts. It's a cold place sometimes. So many terrible things happen that you normally don't allow yourself to get intimate with or interested in any of the people you work with." He remembers feeling embarrassed and uncomfortable about bringing his guitar to his first Department of Surgery Christmas party, and then discovering three others with guitars.
Before entering the operating room, surgeons scrub at a Fleximatic scrub sink, located in a small windowed room directly adjacent to the OR. Each of two stainless-steel basins is equipped with two hook-shaped, high-necked spouts. Faucets opposite each spout give surgeons a choice of a range of water temperatures, but they are controlled so that surgeons cannot accidentally scald their hands. There are also two stainless-steel boxes below each basin so that soap and water can be activated by knee.
Scrubbing is a therapeutic, even a spiritual experience for most surgeons, perhaps especially Marc Rowe, who quotes frequently from a tiny book called Zen in the Art of Archery. The author, Eugen Herrigel, a German philosopher who went to Japan in the 1930s to take up the practice of archery toward an understanding of Zen, writes about the importance of the many customs of preparation—the "meditative repose" in acquiring "that collectiveness and presence of mind without which no right work can be done." Scrubbing is emotionally and intellectually soothing, and it begins for the surgeon that process by which the irreplaceable tools of his trade—the hands and fingers—become first cleansed and then integrated with the mind. After about ten minutes of solitary scrubbing, using a collection of brushes, a fingernail pick, and great quantities of yellow odorless soap, Marc Rowe, fifty-eight, dressed in blue scrubs, with blue paper covers over his running shoes, backs into the operating room, pushing the door with his neck and shoulders, and holding his hands in the air, ready to be gowned and gloved by the waiting nurse.
In contrast to most of his colleagues in surgery, which is typically an upper-middle-class profession, Rowe, a one-time merchant seaman, is deeply rooted in the working class. He has long identified with the disadvantaged, the underdog, in American society, and enjoys telling the story about how he suddenly decided, in his senior year of high school, that he might like to go to college, and how he went to his high school guidance counselor about scholarship opportunities and applications.
"A few days later, one night after dinner, there was a knock on our front door. I was up in my bedroom, and I went out in the hallway to see who it was. It was one of my teachers, who had come to tell my parents, both blue-collar workers, in a polite and embarrassed manner, that their son's sudden interest in college was unrealistic and ill-advised, and that I was intellectually limited, and that I would do much better in life if I took up a trade. In fact, my father was so impressed with this advice that he enrolled me in welders' school following my graduation." A last-minute reprieve came when Rowe won the state high school middleweight wrestling championship in an upset match that earned him a scholarship from Brown University.
Much of his attitude and approach to life and medicine today stems from his experiences as a wrestler and gymnast. "You watch guys who work together on a trapeze. One guy is the swinger and the other guy is the catcher. At a certain point, a swinger has got to let himself go, and throw himself off the trapeze with every bit of abandon he can muster. If he has any lack of courage or of confidence, if he lingers on there just a split second longer, he'll miss the catcher." That, said Rowe, is how to approach highly complicated and difficult surgery. "Once you decide you're going to do it, you just have to throw everything you've got into it, no holds barred, and zingo, that's it. You gotta go all out."
Of late, Rowe has become a marathon runner. "I once was running in the Orange Bowl marathon, and I came up on some guy, and he looked to be in very bad shape, and I ran beside him and I said, Are you all right?'
"He said, 'Yes, I'm all right.'
"I said, 'You don't look all right.'
"He said, 'The only way anybody is going to get me to stop is if they shoot me. Because,' he said, 'I'm going to finish this son-of-a-bitching race.'
"Well, it's the same thing in surgery. It's not worthwhile to just do it half way. If you're not going to try to win, there's no sense in doing it at all. But I'm realistic enough to know that you don't always win no matter how hard you try."
Despite his success as a surgeon and many international honors and awards, Rowe remains a product of his past. He is a nondescript man of medium height, with the traditional broad shoulders and barrel chest of the wrestler, as well as the "cauliflower" ears. Those ears, combined with an abrupt and confrontational manner, which many of his pediatrician colleagues at Children's call "downright nasty," are clear-cut and intimidating evidence to anyone who meets him that this man is ready and willing to go to the mat, not only in the surgical and athletic arenas but also in life. His manner is punctuated by a thick New England accent and an irrepressible tendency to use four-letter words, for which he is always apologizing to his women colleagues at Children's.
Excerpted from One Children's Place by Lee Gutkind. Copyright © 1990 Lee Gutkind. Excerpted by permission of OPEN ROAD INTEGRATED MEDIA.
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