amputation

He is a three-hundred pound prisoner on the last three months of his sentence, and he is weeping.  He clutches the bed rail and tries not to meet our eyes.  We have told him we must amputate - tomorrow.  He has an infected ulcer on his leg that will not heal, and if we do not remove it, the infection could become systemic and cause sepsis or even death.  There are no other options.  He has already delayed for a month to attempt to heal the wound, but the vascular disease resulting from his diabetes means that there is not enough blood flow to heal, and in fact, that the tissue has already died.

This is my first week on vascular surgery, and I have finally started to get into the groove - even the parts about security checks into and out of the prison floor of the hospital.

The vascular fellow is genuinely empathetic and kind, but we have run out of time and options.  The man begs for a few more days to grieve the loss, but the risk of sepsis increases with each day.  To mt shock, he asks each of the other members of the team our opinions, including myself.

"I trust the surgeon's judgment and recommendations, but it is ultimately your chice.  We are on your team," I told him.  Left unsaid: it is your leg or your life.

He finally consents, but the next day, as we wheel him to the operating room, I see that he is still crying.  He weeps silently even as we prepare him for the nerve block in his leg.  As I touch his arm, he reaches out and grabs my hand.  I reassure him that we are there to take good care of him.  He squeezes as the anesthesia resident seeks the popliteal nerve in the hollow behind his knee.  It will be long-acting anesthetic today.

I stayed up late studying the different compartments of the lower leg,  imagining a careful dissection through the layers of skin, fascia, and muscle.  In reality, it is the simplest operation I have seen because there are no structures to preserve, and therefore no real dissection necessary.  It is also the first of two operations; we are only removing the source of infection, but in the second, the proper stump will be formed for use of prosthesis.

The resident quickly cauterizes/cuts around the circumference of the leg to the bone, and I have the sense of returning to the earliest barbaric days of surgery, albeit with anesthesia and sterility.  There is not the elegant separation of planes and isolation of delicate nerves or blood vessels so common in all other surgeries I have seen, only a simple cut even I can envision.

The resident hands me a thin, flexible blade with two handles attached: the guillotine. With a start, I realize I will be cutting through the bone to finish the dissection.  I place the blade under the bone and saw upwards, rapidly pulling the guillotine back and forth.  The angle is awkward, and the attending physician starts to tease me about needing to go to the gym more as I slow.

I snip the last tendon, and the scrub tech whisks away the... foot? specimen? ... into a basin.

I just conpleted the leg amputation.  It was far less strange or gruesome than I imagined.  The other med students high-five me in the call room for getting to do so much in a surgery.  I was professionally excited as well.  But this is also probsbly one of the saddest days of my patient's life.  My patient,

My patient's anxiety snd sadness juxtapose strangely with a mental image of his foot sitting in a basin, the strange grating sound of sawing through bone, and the med-student satisfaction of gaining a new, albeit sonrewhat macabre, skill.

I will see him tomorrow and follow him for probably all the weeks left of surgery and my third year of medical school.