Chasing a Light Beam – Chapter 8: “The O. R.”
THE O.R.
We see by our outfits that we are both cowboys. If you get an outfit, you can be a cowboy, too.
-The Smothers Brothers
“Doctor Boyle to room eight. Doctor Boyle to room eight.”
Ben Bob rose and addressed his colleagues in the surgery lounge. “Well, time to save another marriage.” No one looked up from his newspaper, since it was a pronouncement they had heard hundreds of times before. Ben stopped at a cubicle just outside the main OR entrance. He sat while he pulled paper shoe covers over his street shoes. He wondered why he hadn’t thought of the idea of these covers himself; like most things used in the OR, the mark-up was ridiculously high. A cap and mask completed his outfit, and he strode into the OR corridor. He was carrying four nylon zipper-cases, each containing a hundred music CD’s. When he reached room eight, he turned and backed into the door latch.
“Good mornin’, ladies,” he greeted the circulating RN, the scrub tech, and the nurse anesthetist. His nude patient was lying supine on the operating table, a plastic endotracheal tube protruding from his mouth. Attached to it was the equipment that breathed for him and delivered the anesthetic gases. The patient’s penis was in the gloved hands of the circulator, Lurlene Benson, and she was furiously scrubbing it amidst a small mountain of chlorhexidene bubbles. It was said that when Lurlene finished prepping a penis, even the onlookers needed a cigarette.
“Hey, Dr. Ben Bob.” Lurlene didn’t look up as she spoke. Her eyes were glued to the project in her hands. She was seventy, she was a Texan, and she played the role of cowgirl-former-torch-singer-recovering-substance-abuser to the hilt. She easily could have made a fortune as a radio shock jock. “Good thing we got an indoor job today,” she lilted, “‘cause it’s gonna be hotter than a fresh-fucked fox in a forest fire!” It was typical Lurlene, but since there were no unfamiliar trainees in the room, the level of her grossness would be moderated somewhat. She loved nothing better than to see the reaction of a new OR tech to tales of “pussy”, fucking, and fart jokes emerging from an old woman’s mouth. The concept of “sexual harassment” was foreign to room eight.
Ben laid the zipper-cases next to the boom box. “I brought all the CD’s today, Lurl.” He usually let her choose the music, so she’d have one less thing to complain about.
“Didja bring Joe Walsh? I love that sucker.” She launched into the opening bars of “Funk 49″, humming beneath her mask as she seemed to be trying to start a fire with the penis in her hands. She was a trip.
The patient was Louis Bertrand, a sixty-eight year old diabetic Cajun. He suffered from diabetic penile myopathy, a common condition in which the arterioles–the microscopic arteries–in the penis muscle cease to bring an adequate supply of blood to the muscle cells, resulting in microscopic scarring, or fibrosis. The fibrosis prevents the normally elastic muscles from stretching open to receive the rush of blood that forms an erection. In advanced stages, the disorder doesn’t respond to any form of oral or injectable therapy. Mr. Bertrand was about to undergo the implantation of an inflatable penile prosthesis.
“What’s your guess, Lurl?” Ben Bob almost always gave her the chance to voice her expertise on penis sizes.
“Looks like an all-American boy to me, Dr. Ben Bob.” The inflatable cylinders of the device are made in various lengths, so that there is a perfect fit for every patient, like shoes. Ben’s patients, without exception, requested that he implant the largest size made, not understanding that their own penises determined the size of the implant, and not vice versa. The “all-American boy” was Lurlene’s name for the eighteen-centimeter cylinders, since she had seen Ben use more of that size than any other, particularly in the caucasian men. For her, the size truly was a guess, because a good portion of the erectile muscles that would contain the cylinders was not visible inside the body until the incision was opened. Still, she never seemed to tire of the game, and she made a size pronouncement on each and every penis.
Ben left the room to scrub, then returned to don his gown and gloves. His choice for draping was, in his own humble estimation, brilliant. He used a plastic waterproof drape that covered the entire patient. In the center was a iodine-impregnated thin sticky part, through which the penis and scrotum could be pulled without touching any other part of the body. It was designed for use in artificial hip operations, but Ben had adopted it for his implant patients in an attempt to diminish infections, almost all of which originated from the patients’ own skin. There were other precautions as well, so he could not scientifically prove that the drape was effective. Nonetheless, whether it was the drape, the surgical technique, the medications and skin soaps, or a combination of all, his infection rate was under one-percent for a procedure in which three-to-five percent rates were widely accepted. Infections involving artificial devices cannot be treated successfully without removal of the device, so an infection was a failure. Ben experienced very few failures, but he agonized over each and every one. You get no extra credit for getting it right. It was burned on his brain.
Ben made a one-inch transverse incision just above the base of Bertrand’s penis, between the shaft and the pubic bone. He had devised a method to install the entire implant device through the tiny incision, a technique that, so far as knew, was unique among implant surgeons. The cosmetic result was almost perfect, but Ben also felt that the small opening might offer less entryway to skin organisms during the healing phase. Whatever, the infection rate was low, and the patients were happy.
Lurlene clicked the boom box and a nasally voice, backed by dangerous guitars, came forth: “Spent the last year Rocky Mountain way, couldn’t get much higher…”
The operation progressed smoothly and rapidly. Ben had performed over three thousand such procedures, and all of the hospital’s scrub techs had become familiar with his methods, varying only in complicated cases. He incised each of the corpora, the erectile muscle chambers that would contain the device’s cylinders. Blood gushed out. He would not have remained upright if he had seen this sight while at Duke, but now it was just a routine part of his life. He methodically dilated the corpora with metal tools that could have been medieval instruments of torture. More gushing. He next passed a measuring tool up and down the chambers, and determined the total length to be twenty-one centimeters. Lurlene didn’t really understand the internal workings of the surgery, but she was right: Bertrand was an “all-American boy”. Ben chose an implant with eighteen-centimeter cylinders, to be capped on the inner end with a non-inflatable three-centimeter “extender”, a device used to perfect the fit. When Ben told Lurleen which package to open, she showed her dentures and quipped, “Yep, I know my peters.” Ben had no doubt.
The next step in the procedure was the one that always made the male nurses cringe. A long thread attached to the tip of each inflatable cylinder was passed through the eye of a needle. The needle was inserted into a hollow metal rod so that the needle tip was concealed, and a push tool was placed behind it. The rod was advanced in the penile muscle chamber until it was directly behind the head of the penis. By activating the push tool, the needle, with its attached thread, was pushed through the head of the penis to the outside world. The thread was used to pull the inflatable cylinders into the proper position, then cut and pulled free. The head of the penis was left with two little needle punctures side-by-side that for all the world looked like a snakebite.
Ben remembered one old Cajun who came to the office for his first post-op visit. “Doc,” he said with a “tick” Cajun accent, “when I saw doze marks, I tought I might be like Boudreaux, when ‘e went huntin’ with Thibodeaux.” Ben Bob had heard the joke, but he could see the man was pleased with himself for telling it. “Ol’ Boudreaux was hidin’ in the bushes on his knees, and went to take a leak, him. He screamed and said, ‘Thib, a rattlesnake done bit me on the head of my pecker! Run for the doctor!’ Thibodeaux went to the ‘mercy room and axed the doctor what to do for snakebite. He tol’ him, ‘Put your mout’ over the bite and suck out the poison.’ Thibodeaux ran back to the woods, and Boudreaux axed him, ‘Thib, what the doctor say?’ Thibodeaux said, ‘Boudreaux, doctor say you gonna die!’”
The time had come to see what kind of result Mr. Bertrand was going to get. Ben attached the filling tube of the implant to a syringe containing sterile saline. He pumped the saline into the cylinders, and the penis began to expand and rise. “Whoa, Dr. Ben Bob!” It was Lurlene’s voice, speaking from over the anesthesia screen. “His dick’s wakin’ up!” Ben continued to pump until the penis was fully expanded and rigid. Because fluid was the cause of the erection, the penis looked and felt exactly like one normally tumescent with blood. There was some curvature to the right, caused by the pulling of the diabetes-induced fibrotic changes. Ben wrapped his hand around the shaft tightly and worked the shaft in the opposite direction. There was a palpable, and even audible, “pop”, and the penis straightened.
“Now he won’t have to sit down to pee,” Lurleen clucked.
Using an instrument designed to look up into the nasal passages, Ben passed the device’s pump through the tiny incision and into the bottom of the inner scrotum, where Bertrand could easily find it. He turned the instrument around and passed the empty saline-reservoir device through the incision and into the space between the bladder wall and the back of the pubic bone. He filled the reservoir with saline through its connecting tube, and then connected all the tubes together. He tested the device by squeezing the scrotal pump, and an erection just like the one he had produced earlier recurred. Suturing everything shut required another five minutes. Super-glue was used to seal the closed incision airtight.
As Ben admired his own work, the nasally voice from the boom box dominated the room. “I can’t complain, but sometimes I still do; life’s been good to me so far…”
There were two more cases to complete the morning’s schedule. As he left the room to locate Mrs. Bertrand, Ben knew exactly what Lurlene would say. She didn’t disappoint.
“One up, and two to go, Dr. Ben Bob.”
The OR’s in Lafayette were not Ben’s only venue. By the time his experience with IPP’s reached two thousand cases, he was asked by the manufacturers to go here and there to teach other surgeons, so they would be able to increase the companies’ business.
When I was in Italy, I went with Massimo, the manufacturer’s rep, to a private clinic in Rome. Italy has a socialized medical system, where taxes pay for all medical care. Penile implants were not covered by the system, and a Roman surgeon named Antonio wanted to offer the operation as a private for-cash service. I was going to do the surgery at his clinic, and the surgeon was going to collect the fee and learn the technique.
My biggest concern about IPP surgery, even beyond technique, is sterility. An infection will ruin even the most skillfully performed procedure. Massimo had forwarded to the clinic the special instruments I would require, so that they could be autoclaved in advance. On the morning of the procedure, I met the surgeon and his colleagues, we had tiny cups of bitter Italian espresso, and we all changed into surgical attire.
Antonio, with Massimo backing him up for translational purposes, took me into the OR, an unusual place to meet the patient of the day. There was a scruffy middle-aged man, fully clothed in street duds, sitting on the operating table with legs and brogans hanging off the side. Some “buon giorno’s” ensued, and then Antonio gave the man some instructions. The man stood, dropped his pants and shorts, and then hopped back onto the table, on his back, shoes and all. He reached down and pulled up his shirttails to his chest. As we left to scrub, the anesthesiologist did his thing, and the nurse began the prep.
Once the draping was complete, I asked for the special retractor. Some rapid Italian went back and forth between Antonio and the OR nurse; Massimo told me they had forgotten to autoclave the instrument. Antonio barked some instructions, and I watched as the nurse took the instrument in her gloved hands, dipped it into some sort of purple solution, and then handed it to Antonio. I tried to remain nonchalant, but Massimo had to cover his face and turn away to hide his laughter.
During the case, I noticed the anesthesiologist was going in and out of the room, and no one was monitoring the patient during his absence. I asked Massimo what was going on, and after he spoke with Antonio, Massimo informed me that the anesthesiologist was doing two cases simultaneously. The one in the next room was a surgical drainage of a rectal abscess!
The operating light failed, and we had to use a gooseneck lamp with an incandescent bulb, but I got through the case pretty well. As I was finishing the closure, a newspaper reporter popped in, in street clothes, to take some pictures.
On the way back to Massimo’s home in Firenze, I told him there wasn’t a snowball’s chance in hell that the man’s implant would heal properly. When I returned to Italy in six weeks, we went to the Roman clinic again, and there was my man, happy as a mule eating briars, with a perfect result. A chance to cut is a chance to cure.
Over a two-year period, Ben Bob worked with fifty-two Italian surgeons, operating on their patients and teaching the technique. Few mastered it. Toward the end of his tour, Ben remarked to Massimo, “You know, there seems to be something more than just a language barrier here. These guys just don’t seem that smart.” Massimo, who had a PhD in economics and had lived in the States for several years, laughed and said, “They’re NOT that smart. Doctors in Italy work for the government and earn about twenty-four thousand American dollars a year. What kind of a doctor can you get for that? The smart ones go into business, clothing, wines, automobiles, and the tourist trade.” Ben prayed that his appendix would remain intact for the duration of the trip.
Ben was paid an honorarium to do surgery abroad, but in Italy, the American manufacturer guaranteed him a five percent royalty on all IPP’s sold in the country after his training visits. The manufacturer’s parent company was an American pharmaceutical giant. When they decided to divest themselves of all non-drug products, the IPP company technically became Italian. Ben Bob never received a lira of the royalty, and Massimo assured him that the Italian courts were an expensive dead-end.
Once again, things were not as they seemed.
