Last Night in the OR: A Transplant Surgeon's Odyssey

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9780147515339: Last Night in the OR: A Transplant Surgeon's Odyssey

For readers of Henry Marsh's Do No Harm, Paul A. Ruggieri's Confessions of a Surgeon, and Atul Gawande's Better, a pioneering surgeon shares memories from a life in one of surgery’s most demanding fields

The 1980s marked a revolution in the field of organ transplants, and Bud Shaw, M.D., who studied under Tom Starzl in Pittsburgh, was on the front lines. Now retired from active practice, Dr. Shaw relays gripping moments of anguish and elation, frustration and reward, despair and hope in his struggle to save patients. He reveals harshly intimate moments of his medical career: telling a patient's husband that his wife has died during surgery; struggling to complete a twenty-hour operation as mental and physical exhaustion inch closer and closer; and flying to retrieve a donor organ while the patient waits in the operating room. Within these more emotionally charged vignettes are quieter ones, too, like growing up in rural Ohio, and being awakened late at night by footsteps in the hall as his father, also a surgeon, slipped out of the house to attend to a patient in the ER.

In the tradition of Mary Roach, Jerome Groopman, Eric Topol, and Atul Gawande, Last Night in the OR is an exhilarating, fast-paced, and beautifully written memoir, one that will captivate readers with its courage, intimacy, and honesty.

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About the Author:

Bud Shaw grew up the oldest child of a general surgeon in rural south central Ohio. He graduated with an AB in Chemistry from Kenyon College in 1972 and received his MD degree from Case Western Reserve University School of Medicine in 1976. In 1981, he completed a surgery residency at the University of Utah, then trained in Pittsburgh under Tom Starzl, the father of liver transplantation. An internationally renowned transplant surgeon by age 35, Shaw left Pittsburgh in 1985 to start a new transplant program in Nebraska that quickly became one of the most respected transplant centers in the world. An author of 300 journal articles, 50 book chapters, and a founding editor of the prestigious journal, Liver Transplantation, he retired from active practice and the department chairmanship in 2009, and now focuses on writing, teaching and the value of narrative studies in medical education and clinical practice. His prize-winning essay, My Night With Ellen Hutchinson, published in Creative Nonfiction Magazine, was nominated for a 2013 Pushcart Prize and received Special Mention. The father of three adult children, Shaw lives with his wife, novelist Rebecca Rotert (Shaw) in the wooded hills north of Omaha, Nebraska.

Excerpt. Reprinted by permission. All rights reserved.:

Photo by Rebecca Shaw

ACKNOWLEDGMENTS

We can’t know, let alone remember all the people whose presence shapes what we become. At least I can’t, and that’s my excuse for failing to recognize all of those I’ll now leave out, from the teachers who wouldn’t let me get away with mediocrity and the guys who plucked my nineteen-year-old hitchhiking self from the freeway one frigid midnight and spent the next eighty miles trying to convince me to become gay, to the few teachers who worked so diligently at making students feel small and useless and the many more whose patience and faith often felt undeserved yet no less inspiring. They all played a role. That said, I want to recognize a few, not necessarily because they are most important, but because of their persistence.

When I was six years old, my mother made writing stories a work of joy and pride. I discovered an alternate world, one in which I had complete control. Her untimely death changed all worlds forever, infusing a reality I spent decades denying, no matter how real it became. My father taught me to be my own worst critic, from a similarly early age, less with his words than with the intangible signs of his joy and disappointment. He was also my hero, in so many wonderful ways. I miss him horribly.

Until Mr. Leonard Gwizdowski gave me my first C grade in fifth grade, I’d never received less than an A on anything. My mother was outraged with him, but Gwizzy stood his ground and I had to learn to study—really study. Six years later, Mrs. Mildred Veler gave me a required reading list separate from the other students’. “You’re lazy,” she said, and told me to start with Joyce. At Kenyon College, William Klein called my freshman prose verbose and obtuse, Galbraith Crump brought Shakespeare to life, Perry Lenz left America’s great literary heritage deeply imprinted on my soul, and John Ward showed me unexpected joy in Smollett, Defoe, Bronte, Austen, Richardson, and Thackeray.

In Utah, so many surgeons proved critical to my training, including fellow residents, faculty, and dozens of private surgeons. I’m compelled to thank Frank Moody for setting such an annoyingly high standard for all of us and for always pushing me to be my best, despite my resistance. Gary Maxwell did more to lead me into transplantation than anyone. He inspired me with both his compassion and his astonishing abilities.

At Pittsburgh, I learned kidney transplantation from Tom Hakala, Tom Rosenthal, and Rod Taylor. I witnessed the unflinching integrity of Hank Bahnson, the unbreakable loyalty of Shun Iwatsuki, and the unstoppable drive of Tom Starzl. I owe more than I can ever express to Shun for being there to save my sorry ass over and over, and to Tom for being the font from which so many of my opportunities flowed.

In 1985, Bob Baker, Charlie Andrews, Bob Waldman, and, most important, Mike Sorrell and Bing Rikkers put together a proposal that pulled Bob Duckworth, Laurie Williams, Pat Wood, and me from Pittsburgh to Omaha, Nebraska. Together with Joe Anderson, Jim Chapin, Barb Hurlbert, Rod Markin, and Reed Peters, we forever changed the University of Nebraska Medical Center. My appreciation of the risks these people all accepted to make our work such a huge success is undying. Their expertise and dedication were indispensable.

I have many friends who read my earlier work and encouraged me to keep trying, including Jamie and Kyle, Carlos and Kathy, Bill and Chris, Steve and Genni, Mike Duff, and especially Dirk and Cath, whose friendship and faith are unflinching.

This book would never have come to life without the reboot I got from Steve Langan and the many participants in his Seven Doctors Project, the stubborn faith and encouragement of Amy Grace Loyd, and Jonis Agee’s willingness to introduce me to Noah Ballard, who as my agent has brought wonders to my life. The confident enthusiasm that he and Matthew Daddona, the world’s most gently tenacious editor, have brought to this work both astounds and delights me. Bo Caldwell and Ron Hansen unwittingly inspire me, most especially with their grace in success. Lee Gutkind introduced me to creative nonfiction during many sleepless nights together in Pittsburgh; his guidance has been invaluable.

My brother, Steve, and sisters, Mindy and Beth, may not agree with my versions of the events of our lives upon which I’ve shone so much wattage, but obviously my memory is better than theirs. I apologize for repetitively nagging them for details none of us see so clearly anymore, and I thank them for allowing me this indulgence.

I adored Carol for her art, her spirit, and her courage in facing death. I love Chris for our twenty-five years together, for our three children, and for loving me still. Ryan, Nat, and Joe are my real reason for existence, more for the joy they individually bring to the world than for notions of propagation.

Most of all, I thank Rebecca for resurrecting me, for nurturing my art, for keeping me honest, and for trusting me with her unfathomable love. I will always dance with you.

AUTHOR’S NOTE

This is not a work of fiction. The events I have written about happened. That said, I must admit that in re-creating them, I have had to rely mostly on memory, not only mine but also that of many other people who were present or aware of what occurred. I was regularly surprised by how often my most indelible memories were not those of others. This sometimes led us to intense debate, and if we failed to resolve our confusion, I almost always stuck with my version because it felt most faithful to my experience.

Many of the stories involve patients. To protect their identities, I have changed or left out names, dates, places, and other details that are considered protected health information. These stories are thus merely representative of real experiences rather than the experiences of individual patients. I also found relevant aspects of some patients’ stories in public records, including newspaper and television archives, obituaries, court records, and social media sites.

I was a transplant surgeon and most of my patients were recipients of liver transplants. Their stories are sacred. Their wait for a donor on the one hand and the heroism of organ donation on the other remain the most compelling part of the transplant story. I, almost as much as our patients, owe everything to the donors; more specifically, to their survivors who gave consent for donation. Without those acts of grace and courage, none of the patients I met would have survived, and I would never have experienced the joy and despair of trying to save them. Like many professionals who care for these patients, I lived every day of my clinical career with the horrible reality that more than half the people awaiting organs will never get them. We all long for the day when that is no longer true.

PART ONE

Expectations

Pittsburgh 1981

Initiation I

I was desperate to show how good I was that night. The patient was Max Stinson, a liver surgeon from Texas who, ironically, had a congenital form of liver disease that had finally progressed to liver failure. He was already opened up on the operating table when we got back from Virginia with the donor liver. Shun Iwatsuki was scrubbed in and had half a dozen other people helping him. Most of them left when we scrubbed in, but Shun stayed.

Dr. Starzl wasn’t happy. Shun stood across from him. He had worked with Starzl in Denver and in the course of time, no one would be more important to my training. Dr. Hong from Shanghai stood to Starzl’s right. His job was to retract the rib cage out of Starzl’s way. He held on to the upper wound with both hands and leaned back like a water-skier. I would soon learn they called him the Human Retractor. Carlos Fernandez-Bueno was in his second year of training. He, too, had come from Denver, but by fall he would leave to accept a job he couldn’t refuse at a prestigious East Coast center.

Starzl immediately began complaining. Shun kept silent and moved like a cat to retract something one way, push something else another, and, without a word, get Hong or Carlos to do something useful. I thought them telepathic, and this was their desperate attempt to appease the angry alpha. Already I doubted my own survival, useless as I was in this new world.

Shun’s incision was shaped like the arms of a flattened Mercedes hood ornament, with a short vertical line coming downward from the base of the sternum to join a broad inverted V that stretched from one side of the abdomen to the other. Except for the donor in Virginia earlier that night, I’d never seen a body split so widely before.

I caught a glimpse of the liver lurking under the diaphragm. It was a shriveled, knobby, greenish-yellow lump. It was much too small for the space around it and it sloshed around in a puddle of blood every time the ventilator fired and pushed the diaphragm down.

Blood seemed to be coming from everywhere. The skin of the abdomen below the incision was a translucent, muddy yellow and coursed with giant blue veins running outward from the navel. I could see that the incision transected the course of some of these vessels, and when Starzl started removing sponges from around the edges, those veins rivered dark and red.

Starzl worked furiously to stop the bleeding. He lashed the open veins with silk sutures, grabbing needle holder after needle holder from the scrub tech as Carlos, then Hong, then Shun grabbed the ends and tied them down snug. I grabbed one when I saw my chance and broke it on the second throw.

“Shit,” Starzl said and threw another stitch where I’d broken mine. This time I pulled too hard and the silk pulled out of the tissue and a blood torrent erupted. Carlos grabbed a sponge and pressed down, then got out of the way just as Starzl threw another stitch and tied it himself. He threw two more in the same spot, Carlos tied one and Shun the other, and finally the bleeding stopped. Shun frowned at me and vaguely shook his head.

I decided I could cut the ends of the stitches after they tied them. It was a job we gave to medical students. I was a trained surgeon, and a good one by all accounts back in Utah, where I’d finished my training less than a month earlier. So I grabbed a pair of scissors and cut the suture.

“Too short, goddammit,” Starzl said. “That’ll come loose and he’ll bleed to death. Is that what you want?”

He laid down another stitch and Shun tied it, four throws, and I cut it.

“That’s too long,” Starzl whined. “Come on, now, Shun. Help me. He doesn’t know what he’s doing.”

 · · · 

I worked my last day as a surgery resident at the University of Utah on June 30, 1981. I was thirty-one years old and I wanted to be a transplant surgeon. Dr. Thomas E. Starzl, the father of liver transplantation and perhaps the most renowned transplant surgeon in the world, had granted me a position to train with his team. He had moved his transplant program to Pittsburgh only six months earlier. I’d grown up in Ohio but I’d never been to Pittsburgh. I hated their football team, the Steelers, because they always beat my beloved Cleveland Browns.

My wife and I sold her car, gave the pickup truck to a friend, loaded my car and everything else into a rented truck, and headed for Ohio before dawn on Saturday, July 4. Eight miles east of Point of Rocks, Wyoming, we hit an antelope yearling just as the sun rose above the rocks and sage. In Omaha we drove through smoke from a grass fire started by fireworks. In Ohio we unloaded the truck into my father’s garage. I turned in the rental on Monday and called Starzl’s Pittsburgh office the next day to ask advice about where to find a place to live.

I had arranged to take the month of July off. I figured five years of surgery residency and the specter of a two-year fellowship in transplant surgery justified it. We’d get a place to live and move in and I’d have nearly three weeks to do whatever I wanted. It would be like summer vacation when I was twelve.

The secretary in Starzl’s office put me on hold. She said I needed to talk to someone else.

A female voice with a strange twang I’d later recognize as Pittsburghese came on. “Dr. Shaw? Where the hell are you?”

I said I was in Ohio, at my father’s house.

“You were supposed to be here last week,” she said. “July first, you know?”

She didn’t understand. I’d talked to someone in March. A woman, I said. She promised to tell Dr. Starzl. I wasn’t supposed to start until August.

I looked at the calendar on the wall above the phone in my dad’s kitchen. “Saturday,” I said. “August first.”

“We don’t have any information about that, Dr. Shaw,” she said. “Dr. Starzl expected you last week. You’ve already missed two nights of call. I suggest you get your butt here today, tomorrow at the latest.”

That was Tuesday morning. By Thursday night, we’d driven to Pittsburgh, put money down on a house a few blocks from the hospital, moved what we could with my dad’s pickup, and found a grocery store open after ten p.m. I made my way to the hospital Friday morning and that evening my wife called to say the refrigerator had died. On Saturday I was on call when someone broke the window out of my car on the hill above the football stadium. They stole my toolbox and a Utah Jazz coffee mug. Sandee told me she wouldn’t have parked up there.

Sandee was a nurse on the transplant team. She led me around the hospital my first day and told me where not to park on my second. When we went to the adult intensive care unit, a young woman in a short white coat and a shiny new stethoscope draped around her neck asked me to sign a petition banning liver transplants.

“They’re unethical,” she explained.

I wanted to laugh but she was so earnest. I said I was the new transplant fellow.

“Oh,” she said. “Then you should definitely sign it.”

She told me that in its first six months, the new transplant team had done six liver transplants and all six patients were dead.

“One time they ran out of blood across the whole state of Pennsylvania,” she said. “Shut down surgery everywhere for days. It was awful. Gruesome, actually.”

Sandee said the young woman was exaggerating. The blood shortage thing only happened one time; it was only in Allegheny County and only for part of a day.

“And the kids are all doing great,” she said.

“The kids?” I said.

“All six of them,” Sandee said. “Alive and well.”

“Oh, so then you’re batting five hundred?” The medical student stood with her head cocked, her clipboard resting on her hip.

“This ain’t baseball, sweetie,” Sandee said. She grabbed my arm and pulled me away and through the automatic door into the hall.

The University of Pittsburgh didn’t have any place to put Starzl and his team when they arrived six months earlier, so they parked him in an unused laboratory, a huge room cleaved by long lab benches, complete with working sinks and gas jets. I shared a desk with the other transplant fellow. It was against the wall between two benches and the phone lines ran overhead, held to ceiling tile frames with bread-bag twist ties. Sandee said it was temporary.

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