An Upside Down Puzzle

by Andrew Thomson

At 8:30 on a Tuesday morning, I walked into my first surgery room. I say walked because I had previously been wheeled into the O.R. Back then, I was 8 years old, lying  disoriented  on a stretcher with a badly broken arm and my extremely anxious mom hovering by my side. But now I was 18, standing on the other side of the Plexiglas, staring at what would soon be a scene filled with vitality and blood: a patient was scheduled to have a part of her bone excised and replaced with polished cobalt-chromium and titanium alloy replacements. Wide-eyed and nervous to touch or step on anything, I followed the O.R. nurse to a small space in the back of the room where I would be allowed to observe.

The end of my senior year of high school left me with a tendency toward  laziness and complacency. Change was needed if I was to ever survive the challenges of college that loomed right around the corner. What I thought I needed—what my mother knew I needed—was more discipline in my life. So I applied to a hospital’s summer research program in order to dedicate myself to something that requires commitment and hard work. After interviewing and describing my interest in biology classes and the field of medicine, I was accepted to an internship that also gave me the opportunity to watch a day of surgeries from the P.I. of the lab for a New York City orthopaedic surgeon. 

This internship exposed me to a passion: working with my hands in a way that was precise, efficient, and careful. Monotonous and seemingly boring tasks such as filling small blue and pink capsules with antibiotics somehow became something I looked forward to every day. Scoop. Weigh. Adjust. Pour. Repeat. Balancing the lengthy spatula to reach into the glass-encased balance was sometimes difficult, but the meticulous work   that went into each vial was noticeably relaxing and brought a sense of satisfaction. I would put my headphones on and listen to music as the time quickly passed by; before I knew it, I had finished my 100 capsule quota and was ready to move on to the next task. Carefree days like these, in addition to the eye-opening moments in the O.R., made the summer quickly exceed expectations.

As I stood in my small corner of the room eagerly waiting for the procedure to begin, a part of me was intentionally sharpening my focus (aka ADD) for what I expected to be hours of diligent work ahead for the doctors. When people imagine surgery from TV or a novel, they picture stern-faced doctors staring down grimly at a limp body, unmoving and exposed.  It was the image I thought I was going to see while observing my first surgery, so it was unexpected when Earth Wind and Fire’s “September” began playing through the overhead speakers briefly after the patient went under anesthetics. The atmosphere had completely changed and the doctors began their skillful performance.

The team of doctors worked incessantly, like veteran assembly line workers, to accomplish the beautifully chaotic surgery. Some pieces of bone flew as they shaped the femur and tibia in order for the implant to fit perfectly. Staring through a small opening in the Plexiglas that was intended for sterile tools to be passed through, I bobbled to try and find the best angle to see the action. At one point, I was almost hit by a flying mass of bone and marrow about the size of a clementine, and I was shocked to see that part of it stuck to the Plexiglas in front of me. My mouth remained ajar; astonished. Briefly after the replacement was in and tested for maneuverability, the leg was carefully sutured up, the groggy patient moved out, and the cleaning crew moved in to complete their work. After that, it was on to the next patient. To my surprise, the next surgery would be different. Once comfortable, interns could “scrub in” with the doctors and move beyond the Plexiglas, in order to be right next to all of the action. 

Not at all comfortable, but also not willing to pass up the opportunity, I followed one of the Fellow’s exact movements as we prepared to re-enter the O.R. An integral step was to scrub our entire arms with abrasive Povidone-Iodine pads (where “scrubbing in” gets its meaning) in a large metal sink out in the hallway. “Remember to get under the fingernails and between the fingers. They always forget to get in between the fingers,” said the Fellow. After we cleansed our arms of all the bacteria that could escape if the double-layered gloves somehow ripped, we washed the water from our hands down off our elbows. Then, walking with our hands up as if at gunpoint, we shuffled into the surgery room and filled in around the operating table to be suited in bright blue gowns and white gloves by others who were waiting. The next patient already had her incision and preparations were being made for the bone saw. After gingerly stepping to my spot in front of the patient’s left leg, I suddenly realized just how close I was to everything that was about to happen.

Suddenly, the saw leaned in as the knee pivoted. The dry smell of bone dust filled the air as the odor made it through the filters of our headgear. Occasionally, our facemasks would be spattered with airborne blood and marrow. My eyes were, yet again, only a few meager inches away from exposure to possibly biohazardous tissue. The O.R. nurse previously explained when the clementine almost struck: “If any of that even got on your shirt, you’d have to go through two exhausting weeks of antiviral and antibacterial drugs, for insurance reasons.” At the same time as the precise new angles of the knee were being chiseled by the head surgeon’s shining metallic blade, others were dealing with the blood that was escaping the bottom of the incision at a considerable pace. The answer to this problem? Use a small tool to char the flesh closed at the opening. My seemingly insignificant duty: to waft a small smoke extractor when the pungent vapors came up from the scorched tissue. This apparently mundane and easy task seems simple before you realize the trouble of not bumping the extractor into the surgeon, with the patient’s bone a few inches away. The difference in detail as compared to the first surgery was stark. My awe, however, was not shared by the rest of the team—or at least they did not show it. After the bleeding was stopped and the bone sculpted, the foursome eagerly moved on.

Next was the cement. I was given a lump of green cement putty from the technician who had just mixed it and told me to drop the small glob when I could not hold it anymore. The others continued without intermission to make sure that the new joint would fit the bone by using special implant models to confirm the measurements. Then the cement was laid and the prosthetic fastened. While the cement hardened, I watched as they didn’t waste a second, already beginning to use the suturing materials. I dropped my putty, which suddenly felt like a baking coal in my hand. *PLONK* The team of four stopped what they were doing and looked at me and then the ground by my feet. “Well, the cement’s ready!” exclaimed the head surgeon. Everyone briefly chuckled at my bewilderment and then got back to work. I cracked a small smile through my facemask. 

The intimidating nature of the procedure had left my head. This looked fun, really fun. A seemingly complex set of ideas and processes could now be simplified in my mind: they were fixing something that was broken, giving new hope to a limb that had lost its function. Remove. Replace. Repeat. The O.R. was a finely-tuned machine with humans as a vital component. There is a compelling attraction in seeing this machine at work; surgery is perhaps the ultimate dichotomy of simplicity and intricacy.

I walked out the large glass doors of the hospital lobby still partly bewildered, but also partly invigorated. Would I be back? I was not sure, yet I could not help but see a connection between those surgeries and the puzzles from my childhood. When I was younger, my grandfather would often challenge my little sister and me to take apart and re-solve his upside-down puzzles. He would always solve his 1000 piece puzzles this way because of how much more rewarding it felt when his “masterpiece” was complete. When watching him, it didn’t make any sense how quickly and efficiently he could connect the pieces; it seemed natural, effortless. At first, when attempting to resolve small sections of my grandpa’s already completed puzzles, I struggled to even fit two pieces together. To me, learning how to perform a surgery is much like trying to take apart and re-solve a puzzle upside-down. At face value, the task appears daunting and seemingly impossible, a job that would take an incredible amount of time and effort. Once, however, you can wrap your mind around the meticulous procedure and then practice your process as you go along, the difficulty is forgotten. The rest flows smoothly, and before you know it you have completed your masterpiece.