When I enter the treatment room I always ask my patient to confirm the procedure they’re expecting me to perform. I find this is the best way to avoid injecting the wrong joint, removing the wrong mole, etc. Why make malpractice lawyers’ jobs any easier than they already are? After I’ve verified we’re both on the same wavelength I begin to gather the necessary hardware. If my patient has that familiar white-knuckled look I’ll chit-chat with them as I assemble the supplies. First I place my latex-free gloves on the counter behind me. I then open the biopsy tray and pile the scalpel, needles, syringes and suture material onto it. Next I pour chlorhexidine into the stainless steel bowl. After instructing the patient to lie down, I adjust the spotlight to ensure the lesion is optimally illuminated. When I’m satisfied with the lighting I put on my disposable blue facemask. Breathing with the facemask on always makes my glasses fog up, so after a few seconds of looking like a total loser I dispense with the glasses and deposit them on the counter. I snap on my gloves with dramatic flourish, draw up the local anaesthetic and whirl like Zorro to face the doomed lesion (okay, so maybe not quite like Zorro). I wash the skin with the antiseptic solution and drape clean towels around the area to maintain a sterile surgical field. I give fair warning that I’m about to start injecting, then infiltrate the vicinity with the anaesthetic. Once my target is fully frozen (does this hurt? – poke, poke) I’m ready to proceed.

I gently rest the blade of the scalpel on the surface of the skin. A moment later I apply firm downward pressure. As the blade bites into the tissue I begin carving an ellipse around the lesion. Sometimes bright red blood wells up through the incision, forcing me to stop and compress the area with a wad of gauze until it settles. Fresh blood has an unmistakable odour. I used to find it disturbing, but now some days I hardly even notice it. When the field is no longer obscured by blood I resume cutting a swath through epidermis, dermis and subcutaneous tissue. Once the ellipse is complete I fillet the chunk of flesh out and drop it into the specimen jar. Oftentimes I’ll put a couple of dissolvable stitches deep inside the wound before closing the more superficial layers with regular suture. I dry the skin with some fresh gauze, slap on an adhesive dressing and voila!  Mission Accomplished, as Dubya would say.

For most physicians, these basic procedures become automatic. Like driving a car, once the skill has been mastered we no longer need to devote every iota of our attention to the process every time we do it. For certain tasks it’s safe to temporarily activate cruise control and give the overseeing, self-aware part of our brains a chance to disconnect and take a breather. Don’t worry – it checks in regularly to monitor how things are going. It just doesn’t strain to analyze and micromanage every nanosecond of the procedure. It’s a useful little technique that helps stave off burnout.

Another tactic we often use to help us cope better is disengagement. We separate ourselves from some of the inherently distasteful things we’re required to do every day by mentally stepping back and viewing our actions from a distance. I'm not sure whether the process is partially under conscious control or if it's completely subliminal, but either way it’s a nifty trick. It doesn’t work perfectly every time, though. Once in a while I’ll be poised to begin a procedure when it will suddenly occur to me that my mind hasn’t yet slid into its neutral “physician mode.” In other words, the non-medical part of my cerebral cortex hasn’t politely stepped aside to let the Vulcan take over. Worse yet, occasionally the veil lifts right when I’m smack dab in the middle of something. When this happens I become a doctor with John Q. Citizen’s viewpoint. This has the effect of transiently turning my perspective on what I’m doing inside out, which can lead to some jarring observations. For example, when the biopsy scalpel I’m wielding punctures my patient’s skin and rivulets of blood start to flow, every now and then I think Holy crap! I just cut this guy with a scalpel! What’s that all about?

Sometimes this parallactic view makes me consider other procedures in my therapeutic repertoire in an entirely different light:

Rapid sequence intubations – I give critically ill patients drugs that completely paralyze every voluntary muscle in their body. I then glide a plastic ET tube past their inert vocal cords in order to manually take over the process of breathing for them. If I can’t get the tube in, their risk of a bad outcome increases exponentially. Zoinks!

Chest tube insertion – I dissect the chest wall of a conscious person down to the level of the lining of the lungs, then stuff a tube the size of a garden hose into their pleural space in order to drain air, blood or pus. Seriously?

Neonatal resuscitation – I try to insufflate life into floppy, blue newborns. Did I really sign up for this?

Lumbar punctures – I slide a four-inch needle between two of the lower lumbar vertebrae in order to obtain a sample of cerebrospinal fluid for laboratory analysis. Just think of it as the human equivalent of maple syrup tapping… .

Central lines – I insert sasquatch-sized IVs into people’s necks for better venous access. Ack!

Corneal foreign body removals – I use needles and spinning brushes to scrape fragments of metal and other embedded objects off the surface of patients’ eyes. Hold still now… .

Assisting at laparotomies – I help the surgeon open someone up and exteriorize their guts for inspection and repair. Are you kidding me?

Prostate exams – I…whaaat? Let’s not even go there!

Fortunately, these unexpected episodes of viewing things through non-medical eyes are so short-lived, they’re almost stillborn. Their evanescent nature allows me to quickly return to the strange realm of Asclepius where things that would under normal circumstances be considered outrageous are, for now, perfectly acceptable. I believe this mental sleight of hand is one of the Jedi mind tricks that allow us to perform unpleasant procedures without becoming overwhelmed by them. I also suspect it may help prevent us from getting hopelessly mired in an endless loop of recursive thoughts.

But then again, what the hell do I know?

Sometimes the Voices Are Real…  .

Last Tuesday my morning office went into double overtime. When it finally wrapped up I went to the hospital to see some inpatients. My rounds there finished at 1:25. My afternoon office was scheduled to begin at 1:30, so I decided to skip lunch. Unfortunately, within a minute of making that decision I was feeling so wretched I could hardly stand myself. For those of you who don’t know me, just ask Jan - nobody does pathetic like I do. I hopped in my car and drove to Tim Hortons with visions of a chicken salad sandwich dancing in my head.

As I pulled onto the far end of the lot I happily noted there were no cars in the drive-through lane. What fabulous luck! I was cruising towards the microphone when suddenly Methuselah’s older brother shuffled out from between two parked cars and directly into my path. I mashed on the brakes. He stopped and turned to peer at me through incredibly thick glasses. I waited for him to give some modest display of apology – a nod or wave or perhaps a sheepish half-smile. Instead he curled his lip harder than Billy Idol and continued on his way. By the time he finished creaking past, another car glided in from the opposite direction and stopped at the drive-through microphone. I pulled up behind it, gnashing my teeth and cursing Geritol under my breath. I briefly contemplated leaving, but I was too hungry. I decided to wait and see what they ordered. If it was something quick like coffee, I’d place an order. If not, I’d leave.