第一次操刀

By Atul Gawande

I had seen the procedure done. Now it was my turn to try. I set about gathering the supplies—a centralline kit（中心静脉导管包）， gloves， gown（外科手术服）， cap， mask， lidocaine（利多卡因，一种局部麻醉剂）—and that alone took me forever. When I finally had the stuff together， I stopped outside my patients door and just stood there staring， silently trying to recall the steps. They remained frustratingly hazy（困惑的）. But I couldnt put it off any longer. I had a page-long list of other things to get done： Mrs. A needed to be discharged（出院）； Mr. B needed an abdominal ultrasound（腹部超声）arranged； Mrs. C needed her skin staples（缝皮钉）removed… And every fifteen minutes or so I was getting paged（呼叫）with more tasks—Mr. X was nauseated（作呕的）and needed to be seen； Miss Ys family was here and needed“someone” to talk to them； Mr. Z needed a laxative（泻药）. I took a deep breath， put on my best dont-worry-Iknow-what-Im-doing look， and went in to do the line.

I placed the supplies on a bedside table， untied the patients gown behind his neck， and laid him down flat on the mattress， with his chest bare and his arms at his sides. I flipped on a fluorescent（荧光的）overhead light and raised his bed to my height. I paged S. to come. I put on my gown and gloves and， on a sterile（无菌的）tray， laid out the central line， guidewire， and other materials from the kit the way I remembered S. doing it. I drew up five ccs of lidocaine in a syringe（注射器）， soaked two sponge sticks in the yellow-brown Betadine（碘伏）antiseptic solution（消毒液）， and opened up the suture（缝合线）packaging. I was good to go.

S. arrived. “Whats his platelet count（血小板计数）？”

My stomach knotted. I hadnt checked. That was bad： too low and he could have a serious bleed from the procedure. She went to check a computer. The count was acceptable.

Chastened（受到懲戒的，审慎的）， I started swabbing（擦）his chest with the sponge sticks. “Got the shoulder roll underneath him？” S. asked. Well， no. I had forgotten this， too. The patient gave me a look. S.， saying nothing， got a towel， rolled it up， and slipped it under his back for me. I finished applying the antiseptic and then draped（用布帘覆盖）him so only his right upper chest was exposed. He squirmed（蠕动）a bit beneath the drapes. S. now inspected my tray. I girded（做好准备）myself.

“Wheres the extra syringe for flushing the line when its in？” Damn. She went out and got it.

I felt for landmarks on the patients chest. Here？ I asked with my eyes， not wanting to undermine（削弱）my patients confidence any further. She nodded. I numbered the spot with lidocaine. （“Youll feel a stick and a burn now， sir.”） Next， I took the three-inch needle in hand and poked it through the skin. I advanced it slowly and uncertainly， a few millimeters at a time， afraid to plunge it into something bad. This is a big goddam needle， I kept thinking. I couldnt believe I was sticking it into someones chest. I concentrated on maintaining a steep angle of entry， but kept spearing（刺进）his clavicle（锁骨）instead of slipping beneath it.

“Ow！” he shouted.

“Sorry，” I said. S. signaled with a kind of surfing hand gesture to go underneath the clavicle. This time it did. I drew back on the syringe. Nothing. She pointed deeper. I went in deeper. Nothing. I took the needle out， flushed some bits of tissue（组织）clogging（堵塞）it， and tried again.

“Ow！”

Too superficial（表皮的）again. I found my way underneath the clavicle once more. I drew the syringe back. Still nothing. Hes too obese， I thought to myself. S. slipped on gloves and a gown. “How about I have a look，” she said. I handed her the needle and stepped aside. She plunged the needle in， drew back on the syringe， and， just like that， she was in. “Well be done shortly，” she told the patient. I felt utterly inept（无能的，笨拙的）.

She let me continue with the next steps， which I bumbled（笨拙地做）through. I didnt realize how long and floppy（松软的）the guidewire was until I pulled the coil（线圈）out of its plastic sleeve（塑料套管）， and， putting one end of it into the patient， I very nearly let the other touch his unsterile（未消毒的）bedsheet. I forgot about the dilating（扩张）step until she reminded me. Then， when I put in the dilator（扩张器）， I didnt push quite hard enough， and it was really S. who pushed it all the way in. Finally we got the line in， flushed it， and sutured（缝合）it in place.

Outside the room， S. said that I could be less tentative（犹豫的）the next time， but that I shouldnt worry too much about how things had gone. “Youll get it，” she said. “It just takes practice.” I wasnt so sure. The procedure remained wholly mysterious to me. And I could not get over the idea of jabbing（刺）a needle so deeply and blindly into someones chest. I awaited the X ray afterward with trepidation（恐懼）. But it came back fine： I had not injured the lung and the line was in the right place.

Not everyone appreciates the attractions of surgery. When you are a medical student in the operating room for the first time， and you see the surgeon press the scalpel（外科手术刀）to someones body and open it like fruit， you either shudder in horror or gape（吃惊地看）in awe（敬畏）. I gaped. It was not just the blood and guts that enthralled（迷住）me. It was the idea that a mere person would have the confidence to wield（使用）the scalpel in the first place.

There is a saying about surgeons， meant as a reproof（责备）： “Sometimes wrong； never in doubt.”But this seemed to me their strength. Every day， surgeons are faced with uncertainties. Information is inadequate； the science is ambiguous（模糊不清的）； ones knowledge and abilities are never perfect. Even with the simplest operation， it cannot be taken for granted that a patient will come through better off—or even alive. Standing at the table my first time， I wondered how the surgeon knew that he would do this patient good， that all the steps would go as planned， that bleeding would be controlled and infection（感染）would not take hold（扩散）and organs would not be injured. He didnt， of course. But still he cut.

Later， while still a student， I was allowed to make an incision（切割）myself. The surgeon drew a six-inch dotted line with a marking pen across a sleeping patients abdomen and then， to my surprise， had the nurse hand me the knife. It was， I remember， still warm from the sterilizing autoclave（高压灭菌器）. The surgeon had me stretch the skin taut（拉紧的）with the thumb and forefinger of my free hand. He told me to make one smooth slice down to the fat. I put the belly of the blade to the skin and cut. The experience was odd and addictive， mixing exhilaration（兴奋）from the calculated violence of the act， anxiety about getting it right， and a righteous faith that it was somehow good for the person. There was also the slightly nauseating（恶心的）feeling of finding that it took more force than Id realized. [Skin is thick and springy（有弹性的）， and on my first pass I did not go nearly deep enough； I had to cut twice to get through.] The moment made me want to be a surgeon—not to be an amateur（外行）handed the knife for a brief moment， but someone with the confidence to proceed as if it were routine.

A resident（住院医生）， however， begins with none of this air（样子，态度）of master—only a still overpowering instinct against doing anything like pressing a knife against flesh or jabbing a needle into someones chest. On my first day as a surgical resident， I was assigned to the emergency room. Among my first patients was a skinny， dark-haired woman in her late twenties who hobbled（蹒跚）in， teeth gritted（牙齿紧咬）， with a two-and-a-half-foot-long wooden chair-leg somehow nailed into the bottom of her foot. She explained that the leg had collapsed out from under a kitchen chair she had tried to sit upon and， leaping up to keep from falling， she inadvertently（不小心地）stomped her bare foot onto the three-inch screw sticking out of it. I tried very hard to look like someone who had not just got his medical diploma the week before. Instead， I was determined to be nonchalant（冷漠的）， worldweary（厌世的）， the kind of guy who had seen this sort of thing a hundred times before. I inspected her foot and could see that the screw was imbedded in（嵌入）the bone at the base of her big toe. There was no bleeding， and， so far as I could feel， no fracture（骨折）.

“Wow， that must hurt，” I blurted out idiotically（白癡地）.

The obvious thing to do was give her a tetanus（破伤风）shot and pull out the screw. I ordered the tetanus shot， but I began to have doubts about pulling out the screw. Suppose she bled？ Or suppose I fractured her foot？ Or something worse？ I excused myself and tracked down Dr. W， the senior surgeon on duty. I found him tending to a carcrash victim. The patient was a mess. People were shouting. Blood was all over the floor. It was not a good time to ask questions.

I ordered an X ray. I figured it would buy time（争取时间）and let me check my amateur impression that she didnt have a fracture. Sure enough， getting one took about an hour and it showed no fracture—just a common screw imbedded， the radiologist（放射科医生）said， “in the head of the first metatarsal（跖骨）.” I showed the patient the X ray. “You see， the screws imbedded in the head of the first metatarsal，”I said. And the plan？ She wanted to know. Ah， yes， the plan.

I went to Dr. W. He was still tied up with the crash victim， but I was able to interrupt to show him the X ray. He chuckled at the sight of it and asked me what I wanted to do.“Pull the screw out？” I ventured（斗胆说）. “Yes，” he said， by which he meant “Duh1.” He made sure Id given a tetanus shot and then shooed（赶走，轰走）me away.

Back in the room， I told her that I would pull the screw out， prepared for her to something like “You？”Instead she said， “OK， Doctor，” and it was time for me to get down to business. At first I had her sitting on the exam table， dangling（悬挂）her leg off the side. But that didnt look as if it would work. Eventually， I had her lie with her foot jutting off（伸出）the end of the table， the board poking out into the air. With every move， her pain increased. I injected a local anesthetic（局部麻醉剂）where the screw went in and that helped a little. Now I grabbed her foot in one hand， the board in the other， and then for a moment I froze. Could I really do this？ Should I really do this？ Who was I to presume（妄行，擅自行動）？

Finally， I just made myself do it. I gave her a onetwo-three and pulled， too gingerly（小心翼翼地）at first and then， forcing myself， hard. She groaned. The screw wasnt budging（挪动）. I twisted， and abruptly it came free. There was no bleeding. I washed the wound out， as my textbook said to for puncture（刺破的）wounds. She found she could walk， though the foot was sore. I warned her of the risks of infection and the signs to look for. Her gratitude was immense and flattering（使人感到荣幸的）， like the lions for the mouse—and that night I went home elated（兴高采烈的）.

In surgery， as in anything else， skill and confidence are learned through experience—haltingly（犹豫地）and humiliatingly（羞愧地）. Like the tennis player and the oboist（双簧管吹奏者）and the guy who fixes hard drives（硬盘驱动器）， we need practice to get good at what we do. There is one difference in medicine， though： it is people we practice upon.

1. Duh： 等于中文里的“咄”、“废话”，表示作者的问题没必要，因为答案显而易见。