Morbidity and Mortality: A Surgeon Under Exam

If you poke a hole from the belly into the diaphragm and with your fingers clear away the cobweb-like tissues that separate the heart from the spine, there will be just enough space back there to fit your entire arm. And if you put a small incision along the base of the neck, as you do when you remove an esophagus, you might even see, if your forearm is long enough, the tips of your fingers poking out while your elbow remains enveloped by the soft, rubbery stomach and a flap of liver.

It’s tempting to leave your arm in that warm, reassuring space. On the back of the forearm, you can feel the hardness of the vertebral bones, at the tips of the fingers the coolness of open air, and at the elbow, the slithering contractions of the small bowel. But what you will marvel at most, and why you may keep your arm there for just a few seconds longer than you probably should, is the sensation you notice against the patch of skin on the underside of your wrist, that most tender area where mothers gauge the temperature of milk for their babies.

Against that small swath of skin and squirming of its own accord, you will feel the strong, twisting contractions of the heart. And it will remind you as you look down at the open belly and warm skin and bloodstained instruments on the table that the person whose body embraces you is very much alive.

*  *  *  *  

Surgical residency is infamously difficult, so a month before I graduated from medical school, I polled my favorite surgery residents for advice.

“Sleep when you can, eat when you can,” said one.

“Let your fingers do the walking,” said another, pointing to the telephone.

“See a doughnut, eat a doughnut,” said yet another.

One resident told me to draw up a list of the five most important things in my life and then cross out every one of them except the first. “That’s all you’ll have time for during internship,” he said, “and maybe even not much of it at that.”

I kept mental notes on these aphorisms, imagining myself passing them on to others one day. But of all the pithy observations, there was only one that I ever used.

Rob had completed his general surgery residency and was in his last year of subspecialty training when I worked with him. When not operating he displayed an array of nervous, tic-like movements that ranged from machine-gun-fire blinking to bouncing on his toes to passing his hands through his brown, bristle-brush hair.

Despite the never-ending display of frenetic movements, Rob was the most even-keeled resident I had ever worked with. It helped, too, that he managed to find humor in situations that sent most residents screaming off the edge. He was supremely confident and as a result gave me more responsibility and independence than I had ever experienced. I showed my medical student gratitude by throwing myself like a human shield into Rob’s less savory scut work. I made the calls to radiology’s cranky scheduling clerks, drew blood from ornery patients, and regularly ran interference with demanding attending surgeons. “Make sure to ask Dr. Miller a question about amputations,” Rob would whisper to me before rounds. “He loves that stuff and it will keep him out of my hair for a while.”

When I finally went to Rob for advice, I was hoping for the secret of sanity in residency training.

I caught Rob as he was wheeling a patient from the operating room back to the ICU. “Let me think about it a second,” he said, grabbing his patient’s chart and walking toward the nurses’ station.

It was quiet in the ICU. All the patients appeared to be sleeping and some of the nurses were away on lunch break. The floor, freshly waxed, glistened under the fluorescent lights. Rob sat at the nurses’ station writing his postoperative note. I saw his knee jiggling under the table and could not figure out how he kept his pen still enough to write.

Rob closed the chart and motioned for me to move closer to him. “All right, Pauline,” he said. “Here’s my advice.” Not a single part of him was moving; I smiled, thinking that this sudden seriousness might be part of a playful game.

Rob looked straight at me. “Somewhere along the line,” he said, “you are going to kill one of your patients.”

I shook my head, not sure I had heard him correctly. I knew patients would die under my care but my role was to save, not kill, them.

Rob leaned back in his chair, still looking at me. “You may not mean it, but it’s going to happen.” He sat there, absolutely still. I could hear the breathy chorus of ventilators in the background.

“Pauline,” he finally said. “This happens to all of us. It’s part of the job if you’re in it long enough. You’ll just come to accept it as part of the learning process.”

Rob stood up. He put his hand up to his head, removed his surgical cap, and began running his fingers through his hair. The nervous movements had started up again, and I saw him anxiously looking in the direction of the operating rooms.

“Listen,” he said, now walking to the ICU exit. “When it happens to you, you call me and we’ll talk. You’ll understand then. Really.”

As the doors closed behind him, I wondered if what he had said to me was really true. For days afterward all I could think about every time I saw one of my residents or attending surgeons was, “Whom did you kill?” As I went about my duties as senior medical student and budding intern, I wanted to stop every one of them and ask about that patient. How did it happen? Did you know you were doing it? Or did you only realize it later, after the fatal mistake?

Like some festering ulcer, Rob’s words gnawed at my gut. And when, during my second year of residency, it finally happened to me I never talked about it with Rob or with any of my residency colleagues or even with my family. Instead, all I could wonder then as I watched other surgeons walk by was, “How do you ever get over it?”

*  *  *  *  

In the early 1970s, Charles Bosk, then a sociology graduate student at the University of Chicago, spent eighteen months observing a surgical training program. Bosk was interested in how surgeons as a professional group dealt with error. He rounded with them, attended conferences, and went to the operating room. He became in essence a full-fledged member of the surgical service.

During that year and a half Bosk discovered a professional culture that demanded the highest level of competence among its members: infallibility in a highly variable world. He also noted that the surgeons’ group identity was intimately linked to that drive for perfection. While surgeons were free to choose individually how they cared for patients, they had to be prepared throughout their training and careers to be entirely accountable to the professional group for any decisions they made.

Bosk observed that insofar as death was concerned, this accounting was done primarily in Morbidity and Mortality, or “M and M,” conferences. These conferences provided an opportunity for the surgical community to learn by discussing recent surgical deaths and complications. According to Bosk, however, M and M was also a rite where a strong sense of professional coherence was instilled into an otherwise highly independent group of individuals. As Bosk phrases it, these conferences were a special ritual “for witnessing [these errors], resolving the confusion they create, and incorporating them into the group’s history and the individual’s biography.” And this ritual function was so important that even “those accustomed to letting others cool their heels” cleared all other obligations in order to attend M and M.

Bosk’s findings remain essentially unchanged today. If you throw around the words “patient death” to a group of surgeons, they will almost reflexively want to go to M and M. And other than the patients discussed and the surgeons involved, there is little variation in the way M and M conferences are run across the country. Even the manner of presentation—always the passive voice delivered as flatly as possible—is unchanged from Bosk’s experiences. While there are some exchanges that seem calm and reasoned, others are impassioned, and the raised voices and emotions always point, however subconsciously, to something more.

Occasionally deaths are chalked up to a disease’s natural course. More often, surgeons identify a single mistake and categorize it as an error in technique, judgment, diagnosis, or management. Whatever the category, by the end of the conference the surgeons in the room almost inevitably come to the same conclusion: the responsibility for the error—and thus the patient’s death—lies squarely on the shoulders of the attending surgeon.

In rereading Bosk’s work recently (my sister gave me the book when I was in medical school), I found the familiarity of his subjects to be disconcerting; it was as if Bosk had dipped into my brain and culled out memories of M and M. I heard the interrogations from the audience and saw the offending surgeon standing alone under the spotlight. My gut churned as the surgeon under fire shifted, wincing as the old wound was flayed open once again.

Having stood there in that line of fire, I know what that wound is. It has little to do with the conference or the attacks or even the error itself. Rather, it is that horrible sense that maybe it was your fault, that maybe you are truly to blame for your patient’s death.

*  *  *  *  

Dutch Smulder was a sixty-five-year-old World War II veteran, reformed alcoholic, and unrepentant three-pack-a-day smoker who developed cancer of the esophagus when I was a second-year surgical resident. Unruly tufts of blond and white hair offset the downward drag of his jaw; his long face had a softness to its contours, as if there were a prominent layer of fat stowed underneath his facial skin. He was the last branch of his family tree, a gruff, almost flinty, lifelong bachelor who never gave people a lot to hang on to in conversation.

I, of course, fell for him almost immediately.

In the week before his operation, I visited him twice a day for formal work rounds and then would stop by his room during my nights on call. If I prodded, Dutch would warily spit out a few anecdotes about the war. If I laughed hard enough at one of his jokes, he would guffaw, his rubbery lips opening wide and his eyes disappearing in the depths of his cheeks like one of those Chinese wrinkled dogs.

I liked to think that Dutch enjoyed my visits and even developed a kind of teasing affection for me. One evening Dutch complained that he had had problems with the lunch. I immediately thought of his tumor, alarmed that it might be growing so quickly that we would not be able to remove it. He watched me for a moment and then began to laugh. “It’s not because of the tumor, doc,” he said, patting me on the shoulder. “It’s because the food in this joint is so damn awful.”

The night before Dutch’s operation, I went to his room with a consent form in hand. The attending surgeon, I told Dutch, was famous for his skill, particularly with this procedure, and he would perform the surgery while the chief resident and I would assist. Given the scope of the operation, Dutch would likely be in the intensive care unit for a few days afterward.

Dutch nodded and looked at the form. He silently pointed to the list of potential complications that I had written at the bottom. Some of them, such as leaks from the new connections, were specific to this operation; others, such as wound infections, were potential risks of any surgery. I rushed through my explanation; I did not want Dutch to be frightened. “There is a 30 percent risk of some kind of complication and maybe a 5 percent risk of death,” I said.

Dutch looked at me. His mouth was twisted and he fingered a loose thread on his hospital-issue gown. “So you think this operation is the right thing to do, doc?” he asked.

I knew what I had read in books and medical journals, and Dutch fit the profile of the esophageal cancer patient who had the best possible chances of benefiting from surgery. Of course the operation would have to go smoothly and he would have to recover, but those seemed like such minor steps to me.

Without hesitation, I looked at Dutch and nodded. “Yes, Dutch. The operation is the right thing to do.”

Dutch smiled and then took the pen from me, writing his name in shaky script on the line reserved for patients.

“Carry on, doc,” he said. “Carry on.”

*  *  *  *  

I was on call the night after Dutch’s operation. The operation had gone exceedingly well. Through an incision in his abdomen and another at the base of his neck, we had removed Dutch’s entire esophagus. Since the tumor appeared to be localized to a small segment of the esophagus, we had likely given Dutch the best chance possible of survival.

And I, the member of the surgical team with the smallest arms and hands, had been the one who, with my entire arm in Dutch’s chest, confirmed that we could pull his stomach up and reconnect his gut once again.

At 2 a.m. on the night after the operation, I made a quick visit to the surgical ICU. The usual facility was under renovation, so Dutch and the other ICU patients were in a temporary unit, one originally designed for less critical
patients. Dutch was in the corner room. He still had not awakened from surgery and had a tube to help him breathe. The nurses had placed his hands in soft restraints to prevent him, in a moment of confusion, from pulling on the tube or any of his extensive wiring.

“Dutch,” I whispered to him. “It’s Dr. Chen.”

He squeezed my hand in hazy recognition and then fell back asleep.

I left the ICU but half an hour later received a frantic page to return.
Because Dutch was in that corner room, no one had seen him wriggle his right arm out of the restraint and then, in his sedative-addled state, pull out his breathing tube.

By the time I arrived, Dutch’s heart rate had dropped from 95, when I last visited him, to 60. He looked bluish, and I felt the skin on my inner wrists turn cold.

One nurse was struggling to compress Dutch’s chest, while others had wheeled the code cart into the small room and were drawing up medications from vials. I could hear the hospital operator’s airy voice—we called her Glinda because she sounded like the witch from The Wizard of Oz—repeating over and over on the hospital PA, “Code blue, surgical ICU. Code blue, surgical ICU.” I scrambled to the head of the bed and asked the unit secretary to get hold of the senior resident, who that night was on call from home.

The respiratory therapist and I first tried to use a mask to give Dutch oxygen. Each of us pulled up on Dutch’s jaw and cheeks, sealing his flesh against the plastic to prevent any oxygen from escaping around the mask. The swelling in his throat, however, obstructed his trachea, and each of our administered breaths of oxygen would only blow up his cheeks and dislodge the mask from our hands. Looking over my shoulder, I could see that Dutch’s heart rate had slowed further to 45.

Dutch was suffocating.

I called out for a breathing tube and looked inside Dutch’s mouth. All I could see were pink swollen tissues instead of the dark tunnel that would have been his airway. I tried to force the tube down Dutch’s throat twice, unsuccessfully. After the second attempt I looked up at the cardiac monitor again and saw that Dutch’s pulse had drifted down further to 30. The nurses were giving atropine to try and reverse the slowing rhythms of his heart, but we all knew that without oxygen, everything else was futile.

There are moments in the hospital when time seems to suspend itself. Each second draws itself out, and actions take on a slow, dreamlike quality, as if they are replaying themselves even as they occur. As the events unfold before you, observer and participant, you find yourself reacting not with the rational and deliberate thoughts you have been taught, but as if nature, not some professor, had etched the responses into your neurons. In these moments when you are faced with another’s death, it is as if the distillation of all those hours caring for sick patients bubbles to your brain’s surface and what you find yourself doing feels as natural as the most primal of reactions.

Looking at Dutch’s falling heart rate and his swollen neck, I realized that he needed a cricothyroidotomy, an inch-long incision just below the Adam’s apple for a breathing tube. I asked for betadine, a scalpel, and a sterile clamp. I had performed a cricothyroidotomy only once before—on a pig in an Advanced Cardiac Life Support course the week before internship—but my hands acted as if the routine had been embedded in my genes. I poured the betadine over Dutch’s neck, and the brown liquid splashed over the bed and onto my scrubs. I felt the flatness below his Adam’s apple and drew the knife down. I pushed the blunt clamp toward the back of his throat, plunging it into his airway and spreading the steel jaws to create a hole large enough for a breathing tube. I pushed the tube into Dutch’s neck and down toward his dying lungs.

We beat against Dutch’s chest, infused drugs, and delivered enough joules to his body to leave oval burn marks where our paddles had been placed. His lifeless body slid on the bed, pushed by our persistent rhythmic chest compressions; and every time we delivered a shock from the defibrillator pads, his arms and legs would flail like the limbs of a rag doll. The breathing tube was working; the level of oxygen in his blood was probably better than mine at that moment but we were, ultimately, too late. His heart would never start up again.

Forty-five minutes later, I pronounced him dead.

Ten minutes after that the senior resident arrived. “Oh, shit,” I heard him whisper as soon as he caught sight of Dutch. I followed him into Dutch’s room but he ignored me, picking through the scattered EKG tracings on the bed and the lab results strewn on the floor. “What the hell happened?” he asked, looking not at me but at Dutch’s body. I told him, and he threw the scraps of paper he had collected back on the floor.

“Damn it, Pauline. You should have coded him longer, at least an hour. I don’t care if his heart could not start up after forty-five minutes.”

I felt my own heart drop to the floor.

“Now we are going to have to present this guy at M and M and give some reason for why he died.” He walked over to one of the phones to call the attending. “Shit,” he repeated over and over again.

He suddenly stopped and looked at me again. “No, Pauline, I am not going to present this case,” he said. “You are going to do it. You are doing the M and M.”

I listened to him talk on the phone to the attending, and then I went to look at Dutch once more. The nurses were clearing away the needles and blood and preparing his body for the morgue. He looked cold and pale; the breathing tube spouted up from where I had slit his neck.

I stood there without moving. I thought of the summer when I was six and had gone swimming. I went down the pool steps, my legs descending as if of their own accord. As the water of the pool came to my chin, I felt my right leg swing out and step down, pulling me into the shimmering whiteness of water. The sunlight disappeared, along with my breath, swallowed up by the brightness. My feet touched the bottom, and I struggled to push up with my toes. As my head broke the surface, I began to scream, only to sink back down, blinded by the bubbles of my own breath and silenced by the water that filled my mouth and lungs.

As I wept by Dutch’s room, I felt as if I had fallen in the pool once again, each gasp surrendering precious air until I could breathe no more. Except that this time I had taken Dutch Smulder along.

*  *  *  *  

I spent the following week thinking about Dutch, repeatedly going over in my mind each minute of that ill-fated resuscitation and the ten minutes I had spent alone with him beforehand. I tried to remember the squeeze of his hands, the placement of his wrist restraints, the cricothyroidotomy. I even dreamed that I had loosened the restraints before leaving him earlier that night, and the dream was so vivid that I no longer could remember the truth.

But what could I say, I kept thinking, to the attending surgeons, residents, and students who would sit in judgment of me? I had dreaded M and M, but could I bring myself to say that it was I, not the confused patient, who had loosed his hands?

From the stage of the lecture hall, I began presenting. “H.S. was a 65-year-old-male with a past medical history significant for alcohol and tobacco abuse who presented two weeks ago with adenocarcinoma of the esophagus.” Would the attending surgeons discover, I wondered while my voice droned on in that passive haze, that my dream had been the truth, that I had killed Dutch Smulder?

“H.S. underwent a transhiatal esophagectomy, complicated only by excessive facial and neck swelling. He remained intubated and on the ventilator postoperatively.” As I spoke, I hardly noticed the notes melting in my hand but instead felt Dutch’s heart against my wrist. I saw his open belly in the operating room and felt his swollen hand squeeze mine in the ICU. I heard him laughing a few nights before the surgery, making fun of the hospital food yet again.

“At 2:40 a.m., the patient self-extubated.” I bit my lip, trying to keep my voice and face impassive.

“A code was called. An emergent cricothyroidotomy was performed.” The scene flashed in front of my eyes once again: the betadine splashing over his throat, the knife against his neck, and the clamp entering his trachea. I saw Dutch’s skin and lips become blue and heard the beeping from his heart monitor drift off.

“Despite 45 minutes of resuscitative efforts, H.S. was pronounced dead at 3:27 a.m.” I emphasized the “45 minutes,” sure that I would otherwise be held accountable. The room was silent and audience stared at me grimly.

The interim chief of surgery at the hospital stepped up to the podium. I had searched for him the day after Dutch’s death, recounting the events and hoping for absolution. “Well, that’s tough,” he had replied. “Let’s see what happens at M and M.”

His eyes bore into me now and I suddenly became aware of being alone, up front and center stage. “Doctor,” he asked, “what is the standard of care for patients with esophageal cancer?”

I answered with all that I had read and researched but with every successful answer came another more detailed and probing question. Questions from the audience rushed forth about every possible detail of Dutch’s last day until all was quieted by the last question of all.

“So doctor,” asked the department chief. “How do you account for this death?”

I heard the clock in the room ticking. I opened my mouth. The water rushed in once again.

The department chief stepped toward me and began to address the room. “I’ve talked to the nurses who were working that night, to the nurse in charge, and to all the doctors involved in H.S.’s case.” He paused just long enough for me to cast one more glance at the impassive audience. “My frank feeling on this case,” he continued, “is that this unfortunate death was due to an unacceptable temporary ICU setup. I’ve gone back and looked at that corner room, and even I cannot see how anyone could have adequately monitored a sedated, intubated, fresh postoperative patient.”

I remember hearing a murmur of agreement through the audience. Another attending surgeon volunteered the story of her own patient who had been in that corner room and poorly monitored. After that, the department chief excused me and I went back to my seat.

I had been officially absolved of guilt.

As the conference ended, a few attending surgeons and residents walked by and slapped me on the back. The department chief put his hand on my shoulder. “Good job with that code,” he said. “These things happen.”

I walked out of the room, and that was it. Although that attending surgeon would never again perform an operation like Dutch’s in that hospital and a new ICU replaced the temporary one, clinical life continued as it always had. The senior resident smiled whenever we were on call together, the interim department chief grilled others at M and M, and no one ever mentioned Dutch’s name again. And while I ached to share my grief with others besides my best friend, Celia, I could not help but also believe that there was nothing more to do and thus nothing more to say. Dutch Smulder was best left buried along with all the other initialed patients on that morning’s handout in the annals of the department’s Morbidity and Mortality conference.

*  *  *  *  

There is something intensely personal about surgery. Our hands are in our patients’ bodies, caressing them as no lover ever could. All the usual assumptions about propriety are cast away, and we literally throw ourselves in the course of a disease. We use our fingers to break apart the filmy webs of infected loculations, our cupped palms to scoop out clotted blood, and the nails underneath our gloved hands to pry free adherent loops of bowel. Our work is an extension of ourselves but we come to believe much more—that we are our work.

That lesson starts early in our training. I remember not so much the first patient or the first incision I ever sewed closed but the visit I made the following day. I was the junior medical student on the vascular surgery service and that morning the head of the department joined rounds. Our large group entered the patient’s room. After the attending asked the patient several questions and did a cursory physical exam, we all turned to leave. The attending surgeon suddenly spun around at the doorway and went back to pull down a part of the patient’s incision dressing.

“Didn’t you close this up?” he asked me.

I nodded and he motioned for me to come to the patient’s side. The closure looked beautiful to me; the edges were aligned perfectly, each stitch was evenly placed. Even the patient, despite being pawed and gawked over, was beaming.

“Come over and admire your handiwork!” ordered the surgeon with a laugh. “It’s pretty good, isn’t it?” he chuckled. He wiggled his own delicate fingers in the air, as if to emphasize his point: our hands are our instruments, our interventions a direct extension of ourselves.

Over time, the line between our selves and our work blurs. We see a patient walking around and will identify that person as “I did her colon” or “I did his liver,” as if we were responsible for that patient’s actual part. These are narcissistic moments but ones that patients indulge in as well. More than once I have overheard my patients say, “That’s Dr. Chen’s work,” while pointing to the scars I have left behind.

It is hardly surprising then that death for surgeons is more than a passive process. It is immensely and profoundly personal; it is about us. Surgeons will, for example, do everything possible to prevent a patient from dying “on the table.” While trying to keep a patient alive in the OR is an honorable quest, I was struck as an intern by the ritual that occurred once death became inevitable. The attending surgeons would hastily do everything possible to close up and rush the patient out of the OR, even if that patient expired only a few minutes later in the ICU. The first time I saw this happen as an intern, these quick exits seemed superstitious. Later, after I witnessed the second such death, I asked my friend Celia why there had to be all this rushing about. “Because,” she replied, having posed the same question a few days earlier to a chief resident, “a death in the OR means it was the surgeon’s fault, and you have to do everything to prevent that.”

Our fingers, no matter how nimble and graceful, are always tangled up with the fate of our patients, and when one of those patients dies it is impossible to divest ourselves of that sense of responsibility. We torment ourselves with the what-ifs. Perhaps, if we had put that stitch in just a little differently or removed that cancer a little higher up or worked a little longer, then maybe our patient’s course might have been different.

M and M, our professional ritual centered on death, attempts to heal the rents in our professional fabric caused by patient deaths. There are few other opportunities for surgeons to discuss death. We may mention it in passing, but we steadfastly reserve discussion for the conference that will give us, as a group, ritual absolution. M and M requires a public accounting of loss and, in so doing, reconstructs the death into an event that affirms a core value of our professional identity: the need to be infallible in a highly variable world. In this way, M and M is like death rituals in other cultures; it seeks to transform death’s loss into an affirmative experience.

Unfortunately, the very rituals that were meant to heal a community in death can also hinder that process. Peter Metcalf and Richard Huntington, two anthropologists who have studied rituals in funerary practices, write, “Whatever mental adjustments the individual needs to make in the face of death he or she must accomplish as best he or she can through or around such rituals as society provides. No doubt rites frequently aid adjustment. But we have no reason to believe that they do not obstruct it with equal frequency.” In the case of M and M, death is viewed wholly through the lens of personal responsibility. Death is rendered optional; and mortality becomes a quantifiable and correctable error.

By defining death only as the result of errors, we erase the face of the patient and insert our own fiercely optimistic version of immortality. While admirable in some respects, this paradigm also denies our essential humanness. When we refuse to accept our own fallibility, we deny ourselves grief.

In the end, then, M and M may prevent us from reaching what we so desperately want to achieve: the very best care for our patients.

*  *  *  *  

There is a paradox to rituals. While they safeguard the status quo and control unpredictable individual variations, rituals can also inspire creativity. They can supply the framework needed to introduce new meaning to an event.

M and M has in recent years become the focus of a new approach to death and dying. Long regarded as an instrument for denying death, M and M has become one of the primary venues for incorporating end-of-life care initiatives and formally addressing the personal significance of patient deaths. In 2002, the American College of Surgeons issued a new mandate to improve end-of-life care training for surgeons. One of the key vehicles for this change has been the M and M conference. Internal medicine training programs have not only incorporated M and M into their training but have also begun to use this conference similarly as an educational tool for end-of-life care.

Perhaps, the very characteristics that compel us to find fault first with ourselves—that profoundly personal stake in a patient’s death—have transformed this ritual into something greater.

It has been twelve years since Dutch died. Although the attending surgeons at M and M chalked Dutch’s death up to a problem in the temporary ICU’s setup, I continued for years to ask myself about the course of events that night. What if I had taken extra care to tighten his wrist restraints the first time I saw him? What if I had resuscitated him for fifteen minutes more? What if I had not encouraged him to sign the operative consent?

I have cared for hundreds more patients since Dutch died; and with this experience, I understand the events of that night a little differently now, perhaps more as the interim department chief than the young resident I was. I have found some peace, but Dutch still comes back to me. He is a ghostly apparition who appears whenever I see a patient with esophageal cancer, or perform a cricothyroidotomy, or run an emergency resuscitation.

And there is one other event that brings Dutch back. Each July 1, a new class of interns appears on the wards. I watch those interns, remember my first weeks, and then imagine what the years ahead hold for them. I wonder if they, too, will carry the same burdens as the rest of us.

That is when I see Dutch again, signing his name for me and telling me to carry on.

*  *  *  *  

A year after I had finished all my training, a patient died on the wards of the liver surgery service. An intern had examined the patient, left the room, and within minutes was called back when a nurse noticed that the patient had become unresponsive. A team that included the covering attending surgeon tried to resuscitate the patient for close to an hour without success.

One of the nurses called me that afternoon. “I know you are not covering, but would you mind going to see that intern?” she asked.

I walked over to the floor. It looked no different than usual. Nurses were busy in patient rooms, phlebotomists walked by with their plastic picnic baskets filled with gleaming empty tubes and requisition slips fluttering. I walked into the small office reserved for interns. Papers and films were piled about haphazardly. The intern sat huddled over a computer.

I introduced myself. For a moment I saw fear flicker over his eyes, as if he expected me to bawl him out.

Instead, I asked him what had happened and how he felt. He was cagey at first. Then I told him. I told him how hard it was for me and how, years later, I still thought about Dutch. “But you know what?” I said to the intern. “I think I am a better and more compassionate surgeon because of Dutch.”

He sat there, face impassive. I was not sure if I had said too much.

But a couple of days later, there was a knock at my office door. My office was set off a corridor in another wing of the hospital, nestled among cardiologists and far from other liver surgeons. Visitors were rare.

I opened the door and it was the intern. His face was still impassive.

“Just wanted to say thank you,” he mumbled.

As he quickly turned to walk away, I only had time to say, “No problem.” But I spent the rest of the day with Dutch’s grinning face in the back of my mind.