The Operating Room: A Sacred Space

Donald J. D’Amico, MD

“There’s something in your lateral octave, Don; that’s why you’re a doctor.
—Dorothea M. Dooling, circa 1988”

y surgical day begins. I open my eyes to the earliest alarm of the week and remember there will be no coffee this morning. Though it brings a welcome energy, the slight tremor it induces will coarsen my hands and imperil the delicate maneuvers they must perform. With this small sacrifice, I set about my morning routines.

My specialty—vitreoretinal surgery—centers on repairing disorders of the retina in the posterior part of the eye. Retinal detachment is certainly our most well-known condition, but there are many others that cause visual loss that can be improved by surgery. Given the retina’s delicacy, the specialty includes the finest maneuvers performed by the unaided human hand in any surgical discipline, and missteps of even a millimeter can be devastating to a patient’s vision.

As I make my way to the hospital, I review the procedures scheduled for the day and search for anything to be communicated to the operating room staff prior to my arrival, perhaps a special instrument or additional equipment. I also visualize the patients themselves, and they inevitably present a broad mix of surgical and emotional complexity. Some will be recent referrals and others may be longstanding patients; either group may be having an initial operation or one of several reoperations, and their eye conditions can range from straightforward to approaching the limits of present-day operability. Across this wide spectrum of prospects for a successful outcome, I have learned that the emotional attitude of a patient can rarely be predicted by their ocular anatomy. Some will be frightened to undergo even our most successful interventions, while others are prematurely confident of a cure despite a most challenging situation.

For each patient today, our last encounter was a preoperative examination in which a decision for surgery was reached. During that critical visit, I try to see, as clearly as I am capable, the anatomical complexity of a patient’s condition as well as their ability to bear it; I must understand both if I am to have any hope of restoring their vision or helping them move forward with their life if I cannot.

When one imagines being confronted with the demand to act effectively in the most complicated settings, a few powerful examples come to mind. Being asked unexpectedly to take the controls of a jetliner is an example so compelling that it has become a staple in our novels, movies, and perhaps even in our dreams. Stepping into the control room of a nuclear powerplant, with its specialized technicians monitoring hundreds of switches and gauges under the omnipresent shadow of a catastrophic alarm, is sure to move one toward a mixture of awe, terror, and inadequacy. I would suggest that the surgical operating room rivals these scenarios. With its array of specialized participants, high-tech instrumentation, monitors emanating rhythmic but unsynchronized beeps and flashes, unique costumes, ungainly sterile procedure choreography, unnaturally clean smell, and basketball court lighting, it is without question otherworldly. Moreover, unlike the pilot or the nuclear technician, a surgeon enters the operating room with an immediate relationship with the patient, one in which the surgeon’s hands, mind, and heart will meet difficult choices and obstacles at every turn; the former must be decided quickly, and the latter must be surmounted.

Unlike a sculptor or composer whose chisels and clefs have remained unchanged for centuries, a surgeon works with impermanence in every aspect of the craft. The central issue is remaining open to progress while navigating to a successful outcome for the patient. Given the torrent of medical information and new technology, how can one separate what is innovative and important from what is not? In the end, surgeons understand that we cannot know every study or perform surgical maneuver perfectly; we must take our strengths and our inadequacies into the operating room. I suspect the best surgeons carry both with equal welcome.

Unquestionably, the performance of surgery is an intense situation even when it goes smoothly, and when it does not, it can be fraught with stress and terror. An attentive inner posture can be a most helpful anchor, but the question arises as to how to cultivate and maintain it during the inevitable swirls and eddies in the procedure. Certainly, having a broad skill set and practiced routines is critical, and these make one an excellent technician, but several other elements can be engaged and bring the surgeon closer to the moment. One must also be honest about what can be repaired and what cannot; indeed, all surgeons can start an operation, but it takes years and courage to know when to stop one.

Moving through an operation reminds me of crossing a dangerous savannah by barefoot Masai tribesmen; their seemingly simple tools of watchfulness, listening, quiet, deep knowledge, and a wooden spear combine to successfully evade or conquer the many lurking beasts. I doubt their journey is ever exactly the same, nor is mine across any operation. Though my physical tools are stainless steel and lasers—not sticks—the need to be attentive for a successful passage is shared.

If I am able to be more engaged during surgery, with my attention at its widest and my relaxation at its deepest, I have the sense that something noble is occurring and the operating room becomes a sacred space, a solemn place revered and entered for the alleviation of suffering. In these cherished moments, my feeling quietly shifts from doing to participating. On the rarest of occasions, there has even been a sense of transmission; while performing an extremely delicate maneuver, I have had the feeling that if the higher wished to experience the practice of vitreoretinal surgery, they might do so through me.

My surgical day begins. Having changed into my scrubs, I walk into the preoperative area where the patient, spouse, the preop nurse, and my trainees are waiting. Their immediate focus on me during my entry is a helpful reminder to search for the most appropriate tone. I take the patient’s hand and say hello while assessing their state and readiness. In the brief moments that follow, there is reassurance that all is ready in the operating room, some document signing and procedural items, perhaps some brief banter if it feels appropriate. Understandably, there may be last-minute questions, and they are unfailingly about the future, e. g., “When will I be able to see?” “Will I be able to see well enough to drive?” “How soon will I see clearly?” and other variants. These cannot be answered with honesty, so I demur and evade these inquiries. I turn the focus to the present, where action and sincerity are to be found, and simply reassure the patient that the team in the operating room is an excellent one.

As mentioned above, learning to relax in a difficult situation is a critical element in surgical training. Contrary to what many might think, experienced surgeons often find their operating room days to be the least stressful of the week. This has many reasons, beginning with the protection from distractions offered by the phrase “The doctor’s in surgery”—certainly, one of the few remaining appeals for privacy that is still respected. The wonderful lack of intrusions contributes to the feeling that this is indeed a special place. Of course, there are many other joys to be found: working attentively with one’s hands as a craftsman, sharing a trainee’s breakthrough proficiency moments, and most of all, the profound sense of gratitude and fulfillment in the restoration of a patient’s sight or other cherished function.

Indeed, the single most peaceful moment of my life took place in an operating room, though its occurrence could never have been predicted. Many years ago, I had been referred a patient who had lost one eye to a fiendishly complex form of inherited retinal detachment, and the same terrifying process had just begun in her remaining eye. To add to the complexity, she was midway through her first pregnancy, and understandably, given her dismal visual prognosis, her greatest wish was to see, however briefly, her expected child. Given these circumstances and balancing the harm that would permanently ensue if the detachment was not repaired before it reached the center of her vision, we struck a compromise: I would examine her every two weeks for the remaining months of her pregnancy, and we would defer surgery unless the detachment reached the stage where visual loss would become irreversible.

The timing worked, and she delivered a healthy child just days before her detachment reached the danger point and demanded an attempt at repair. Surgery was scheduled for two weeks after her delivery. Resting in the preoperative area with her new child in her arms and her husband by her side, she took a long and potentially last look at her child just before I administered local anesthesia and sent her off to the operating room, both of us aware of the exceptionally high stakes involved. At that moment, the desk nurse informed me I had an emergency call; my teenage son had collapsed for unknown reasons during gym and was in an ambulance on the way to our adjacent hospital. The paramedics in the ambulance told me he had been revived and was now alert and seemed stable. They would have him in the emergency ward within minutes, where his mother, a nurse, would most fortuitously be on hand to meet him. In what should have been a pinnacle moment of unimaginable stress, a confidence appeared that everything possible for my son was in fact in place and that I was needed elsewhere. As I walked down the hall to the operating room, a sense of serenity deepened that I had never before experienced. I watched myself, as though from a corner of the room, perform an utterly relaxed and crisply effective operation. To our shared amazement, her retina was reattached and her sight maintained, and my son’s collapsed lung was treated successfully. Although the experience soon flickered back into the ordinary, its thread in my memory strengthens a reverence for what is possible in the operating room.

My surgical day winds down after completion of the last operation, but something continues. An unbroken thread from millennia ago when a person sought to help another who was suffering from a serious injury or ailment. Perhaps the helper was a shaman or priest of some kind and fortified by a belief in something higher. Regardless of the enabling cause, an inner attitude appeared that allowed them to withstand their revulsion in front of a bleeding wound, their fear of being unable to help, and their grief at the suffering of a loved one. In this detached yet attentive state, they tried to help. Their tools and medical knowledge were certainly beyond primitive by contemporary standards—as I am certain my own will be soon enough. Most importantly, in the face of the many failures that every surgeon knows, they returned to these difficult and even gruesome scenes and tried again. The joy and awe surrounding the rare successes of these earliest surgeons undoubtedly turned to reverence as they quickly discovered that the restorative currents of the body could be explored, followed, and even coaxed, but never commanded. Healing, as every surgeon learns, is something one assists but cannot do. Those first successes must have seemed nothing less than miracles. Yet the recoveries that resulted from this new, privileged touching were different. They were not like the miracles of prayers being answered with rain pouring from the skies or finding a life-sustaining animal on a hunt. For this healing through surgery was a new type of miracle—a miracle that could pass from one person to another.

Donald J. D’Amico, MD, is Professor and Chair of Ophthalmology at Weill Cornell Medical College/New York-Presbyterian Hospital. He supervises physicians-in-training at all levels, and on three occasions has been chosen as Teacher of the Year. Dr. D’Amico is a distinguished surgeon and lecturer and the recipient of many honors. He was the inaugural editor-in-chief of the Journal of VitreoRetinal Diseases and is a past president of the Retina Society and Club Jules Gonin. He began his participation in Gurdjieff Foundation groups in Chicago with Christopher Fremantle and has been a member of groups in Boston, Miami, and New York.