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  Thirty or so years on, walking into one of my exam rooms, I was met by a pleasant 78-year-old lady who was there to see me because of a recently diagnosed colon cancer. She explained that she was healthy except for the lump that had been found on a routine colonoscopy. Although I did not immediately recognize her or her name, perhaps in hindsight I should have. But we tend to remember only the patients we either see repeatedly or those who for some reason have left a mark on us, and then it’s usually not a good one. Difficult cases and bad outcomes tend to leave an indelible mark, whereas routine and even complex cases are rapidly forgotten. The patient acted with a familiarity that made me think I should know her. But I didn’t, at least not at first. She was accompanied by her grandson who also looked at me with a wide smile, friendly eyes and sticking out his hand gave me a zealous, warm handshake, as if we were the best of friends. I still could not put two and two together. After going through perfunctory introductions, I finally just came right out and asked them if we had met before. Not terribly surprising from the way they were acting, they responded affirmatively, and the young man went on to say that I probably would not have remembered him because he was just a baby the last time we had crossed paths. To be more precise, he had been a newborn infant. Lifting up his shirt, he showed me a three-inch transverse scar on his upper abdomen. I immediately recognized the surgery that the scar represented but still did not remember him. However, I was sure that the last time we met he would have had neither the thick locks of reddish-brown hair nor his current deep husky voice. Once he told me his last name, it was as if someone had reached in deep band pulled out apparently long lost memories, as both his name and a vivid recollection of the events surrounding our previous encounter came flooding back. He was a patient who I would never have easily forgotten, not necessarily because the surgery was difficult but more because of everything that surrounded the plan to proceed with surgery.

    Over two and a half decades earlier, when I had been asked to see him, he was three weeks old, having been brought to the hospital by his very distraught parents. He had been vomiting constantly after bottle feeding and was unable to keep anything down. At that time, the mother explained, she had already had two girls, but he was her first boy. She recalled how, although he had acted desperately hungry every time she tried to feed him, he brought his formula back up with projectile force. This, she reminded me, was completely opposite to the way he had been for his first few weeks. Soon after his admission, an upper GI evaluation revealed the problem, as the oral contrast he ravenously swallowed would not exit his stomach. He had pyloric stenosis, a condition that involves a marked thickening of the muscle at the outlet of the stomach, which prevented it from emptying and he from obtaining necessary nutrition. Prior to surgical intervention with pyloro-myotomy (pioneered early in the last century) and routine intravenous fluid resuscitation, this was a grave disorder with a very high mortality, usually as a result of irreversible dehydration. When I first went to see him, it was clear that I had arrived at a significantly inopportune moment, as the nurses had been trying in vain, for some time, to try to get IV access. Surgery without correcting the always-present dehydration is always risky. The family had understandably become both very frustrated and apprehensive, which was certainly not helped by their screaming infant. This caused them to begin inquiring about transferring him to another hospital (Bigger isn’t always a better option.). When I had time to talk to them, I offered that if we were unsuccessful, that transfer was always a possibility, but certainly we had not exhausted all our options. The nurses, usually the experts at getting IVs in, had tried everything. He had multiple small pokes and bruises all over his scalp as testament to their tenacity, but still, all their attempts so far had failed. So, what were our choices? There was always interosseous access, where a needle is placed directly into the bone marrow and used for access. Although it sounds awful, it is a lot more comfortable than the incessant poking to try to get a regular IV in. Although it was not something we did routinely, it was still an alternative that we could call on if required. And now was that time. To be perfectly honest, although I knew about it, I had not personally put one in before, but I didn’t think this was the right time to convey this information to an already distraught family, closing in on their wits’ ends. Opening the package, I rapidly scanned the instructions. It was just as I remembered and seen others do. I knew this had to work. With the nurses holding the infant’s leg still, I carefully prepped the area then rapidly punctured the skin and the bone. I was pleasantly surprised by how easy it was to get the needle in, and within minutes we were giving him the fluid he desperately needed. After rehydrating him overnight, the next morning we took him to surgery, where he underwent both an uneventful and successful procedure to open the swollen muscle that was blocking the outlet of his stomach and allow it to empty. His stay in the hospital was brief, and the smiles across the face of his happy parents were priceless.

   It was not necessarily a very difficult or complicated surgery, but seeing the result 25 years later only consolidated why it was such a joy and privilege to be a physician and a surgeon. In a nutshell, it is always about solving problems, trying to keep patients healthy and families happy. However, not all surgeries have the desired outcome, sometimes because that outcome is not possible. This is, of course, the difficult part of surgical life.