Undergoing life-saving surgery Ronald Aronson realised that there is a force beyond ourselves giving our lives meaning. It just isn’t God
Waking up after open-heart surgery was the most stressful moment of the entire experience. Barely conscious after five hours in surgery, I was too numb to make a sound even if I were able somehow to get the tubes out of my throat; I could not ask for help in freeing my painfully constricted hands tied too tightly to the rails on the sides of the bed. “Hi, Dad!” my daughter smiled at me, as if to say that the surgery was successful and things were going to be all right. I tried to say “Hi,” or “I hear you,” or even to grunt so that she might answer “I see that you can hear me.” Try as I may I couldn’t nod my head. In my frustration I could only blink my eyes repeatedly to let her know I heard her. Did she notice? Could she tell that I was responding to her? Without her saying “I see your eyes blinking, Dad,” I thought that she wasn’t aware that we were connecting. It was only later, when reading the first draft of this account, that she told me that she had been surprised and pleased that I had opened my eyes when she called me, and knew that the blinking was my way of responding. She knew, but I didn’t know that she knew. Lying there immobile, I felt frustrated, trapped in myself, and frightened.
This bad moment passed into a long sleep and by the time I woke up the tubes were gone and my hands untied. I could talk and move, and my nurse said hello to me. I smiled at him and asked him his name. He was cheerful and friendly. I was no longer cut off. I fell asleep again, calm.
During the next months as I puzzled over my experience it gradually dawned on me that I was not most afraid of dying or winding up debilitated, but something more immediate and visceral. Neither illness or aging, not even death, are as terrible for me as being trapped in myself, unable to communicate. Silence, losing connection with others – to me this is a fate worse than death. Much is being made lately about the possible role of religious faith in helping people to weather health crises, serious illness, and major surgery. Specifically, the conversation has been about the reassurance people draw from feeling supported by a power beyond themselves and being connected to a wider community. As a third-generation atheist, my starting points included a Sartrean sense of responsibility and self-determination as well as an activist temperament. Nevertheless, my experience of open-heart surgery generated a powerful sense of dependency on forces beyond myself, of being connected to larger processes, and of being part of a meaningful wider universe.
My ways of experiencing open-heart surgery, strictly limited to this world and this life, connected me keenly with those taking care of me, and the processes and networks making my treatment possible, as well as the long history of medicine and heart care. During this time of danger I never for a moment thought in terms of God or a higher power, nor felt the slightest need for religious faith. But I was profoundly grateful to the forces and individuals beyond myself, called for help and received it, found strength outside of myself, and experienced myself as part of something larger. Although similar to impulses that draw people to God, my way of experiencing is strictly terrestrial – and as my descriptions will show, my sense of connection asks to be rationally analysed and critically discussed.
I fully regained consciousness in my room in the Surgical Intensive Care Unit the evening after my surgery. I was aware of the presence of a quiet, efficient nurse whose whole job was to take care of me—and of my total dependence on her. She had been an oncologist in China before emigrating to the United States and becoming a nurse. She was followed, in 12-hour shifts, by at least ten others over the next week, some assigned to me as many as three or four times, others only once. ICU nurses usually have no more than two patients to attend to – occupying their full time making them comfortable, reading vital signs regularly, drawing blood, making sure all the systems are working, emptying catheter bags, washing them, preparing them for bedtime, preparing them for the new day, attending to emergencies and needs and recording all this. Grateful for their presence, I found myself talking to every one of them, curious about who they were and how they got there, telling them about myself, asking the questions that came to mind about my surgery and recovery. I developed a sense of connection with almost every one of them, intensely appreciating their caring. I wondered how they chose their profession as ICU nurses. What they were doing felt neither like a routine they were performing with indifference for a pay check nor a service I was owed because my health insurance was paying for it. In my state of total dependence it felt like a much more basic social bond: their work is to care for others, and they perform it caringly.
In Living without God I have written about gratitude as expressing our root relationship of dependence on the natural, historical, familial and social forces that make our lives possible. In feeling deeply grateful towards the patient care staff was I responding to something real, which was actually taking place between them and myself, or was I simply expressing the drug-induced haze of a totally vulnerable post-surgery patient? In a heightened emotional state, was my sense of connection coming from my fear, shock, relief, chemical intensity, a totally unexpected sense of relying on people I didn’t know, appreciation that they were taking care of me, an overriding need, perhaps even a survival need, to make some sort of personal contact with strangers who had suddenly become so important to me? Or was I seeing more clearly than usual into a relationship of human solidarity, experiencing a social act of caring that we normally ignore or take for granted? Was I legitimately sensing what work is at bottom, indeed, perhaps even what underlies all social bonds? Still anesthetized, was I placing a halo over ordinary relationships, or was I oddly enough momentarily de-anesthetized, in my drugged state seeing through to a core of caring and contributing?
I want to answer yes to all of these questions, but at the same time refuse the either/or they imply. Of course there was a subjective dimension to my experience, but this is true of all connections between humans. Connections are not just seen, passively observed: they are made, and in doing so people bring everything of themselves into the relationship. Certainly my nurses seemed to be ordinary people like myself. In part they were performing routines that most of them had done hundreds of times over. But each of their patients is a distinctly different person and represents a different set of challenges, and their effectiveness depends on responding to this. From every last one of my care-givers, I experienced gentleness, kindness, and patience, as well as a strong sense of each one’s strengths and personality.
Never did I feel treated as an object, a task to be accomplished, and even in the few instances when my constant questions and reflections caused weariness or even irritation, this was only momentary. I was told later that the nurse who took care of me during the first four nights, and with whom I felt both most vulnerable and most secure, routinely requests the “open-hearts.” One nurse had a delightful, jokey sense of humor, another a wonderful sense of calm; another, a Filipino, was as curious about me as I was about him; a Seventh-Day Adventist and I had a remarkably gentle conversation about her reasons for belief and mine for disbelief. A brilliant older nurse who would I suppose be regarded as a “character” gave succinct, brief, and enjoyable lectures in reply to my many questions. The expressions and musical speech patterns of an older black woman who grew up in Kentucky were so enjoyable that I would ask her questions just to hear her speak.
Why, I asked some of them, were they nurses? Every one was an RN with at least a bachelor’s degree; every one worked 12-hour shifts; none of them had the financial or social power of the doctors. Some of them were strongly pro-union in a situation where the union had narrowly lost a collective bargaining election; one nurse told me that he very much wanted to be represented by a union, but that he worried about what effects strike tactics might have on the critically-ill patients. Some nurses complained that physicians would stroll lordly-like through the ICU noting this or that, ordering this or that. But everyone knew that this is the nurses’ territory, that we were their patients. From all of them I got the sense that this relationship of caring was the most important thing, the main reason why they were here. Of course all medicine is about taking care of people, and this is most acutely so in a hospital. But the most sustained, direct, person-to-person structure of caring is the relationship of nurse to patient, and most intensely so in the ICU. The meaning of the job, and its reward, is this relationship.
I was rolled into Room 54 unconscious, vulnerable, needing constant attention and help – and a week later I was out of danger, functioning, able to feed myself, take care of myself, walking up to 200 feet, tubes removed, ready to go home. The nurses’ job is to help, coax, and prod patients get from one state to the other. There were moments when I felt as if I didn’t want to get there, because every step was so very difficult. I was ready for the fact that every move forward, such as the first agonising step on the leg from which the veins were removed to replace the blocked arteries, required a choice: I had to overcome the desire to not struggle, to avoid the pain. Each step can be so difficult that we feel tempted to quit – tired out, discouraged, angry, defiant. And some patients do refuse to cooperate – a particularly noncompliant one, fresh from the OR, raised a late-night ruckus next door and insisted on putting his clothes on there and then and going home. Nurses are prepared for this. They sometimes encourage their patients, sometimes make demands on them, even sometimes argue with them, occasionally even meeting anger with anger. The intimate process of direct patient care, helping patients strengthen so they are prepared to go home, is their job.
I think that many nurses are in touch, perhaps more than most people, with what work can sometimes be about. “It is,” one of them said simply, “very rewarding.” This is their secret, which goes against so much of the surrounding culture. Exhausting and demanding, their work is about giving, a kind of human solidarity: making a concrete difference in helping people get better. They are fortunate to have this at the center of their work lives.
During my stay in the hospital I had special feelings even about the briefest encounters, as with the exercise therapists who, within a few days of surgery, got me standing up, walking 20 feet, then 40, until before being released I had to walk 200 feet along the corridors. I have seen my intense first impressions of these two young people fade in the months since, especially because I’ve seen them frequently in cardiac rehab. We now have a wholly normal relationship: they staff the unit, take my blood pressure, answer questions, we chat. But beneath such everydayness remains a special memory of how I first saw them, the questions I asked, my intense admiration that they were devoting their days to helping weak, vulnerable, and dependent people. Cynical as everyday life makes us, inured as we become, I still can’t get rid of the sense that I saw and felt something special about these people. And that they are part of a system, built over generations, reaching back to the first steps of medical treatment, whose goal, despite all limitations, is to help people recover from illness.
I recall the last look, the goodbye, of a young nurse whose wife is a maternity nurse – they have two young children – and who drives an hour each way between work and home. I was getting ready to leave and called him into my room because I hadn’t seen him for a couple of days. In the goodbye look – his? Mine? Both of ours? – was a haunting feeling that something very special was ending, that if I ever saw him again I’d no longer be the vulnerable patient filled with gratitude that I had been during our three days together, that he’d no longer be the calming, encouraging, protecting force he had been for me. I’d have my old self-confidence back and my social rank as a professor. I can't say what he might have been feeling, but I do know that our last look contained my question about the critical care nurse-patient relationship: can its closeness, the connection that we experienced, our shared sense of his strength and my need, both of our hard work, my gratitude, still be accessible after my return to normal?
Of course, the nurses are the ones we depend on most directly for the longest time during our hospital stay, and we have privileged relationships with them, especially in the ICU. But during the week after the operation I felt similar connections with the surgeon, the anesthesiologists, the residents and other doctors, the rehab staff whose job was to get me walking so I could go home, the physician’s assistants, the x-ray technicians, and the nurses who give pulmonary treatments to restore lung functioning. And I was keenly aware of a whole world of those who contribute indirectly, such as the woman who swept my room and emptied the trash. She had been working there for eight years because “I like people and need the job.”
Lying in the ICU for hours after the anaesthetic and morphine wore off, I played at sketching the whole operational chart of those who are directly and indirectly involved in open-heart surgery, including those who design, make, and transport the heart-lung machines and instruments such as scalpels and sternal saws, clean the OR and keep it sterilized, are physically and organizationally responsible for the hospital and the health system to which it belongs. We can include those who produce and ship the chemicals and medications, manufacture and ship the cleaning solutions, physically maintain the hospital, process the health insurance paperwork both at the hospital and the insurance company. To visualize the entire process means adding those who train the participants, including in the medical and nursing schools, imagining the vast society-wide integrated network into which thousands of individuals fit directly and indirectly.
Systems, links, networks: few of us are used to seeing things this way, and our individualist social outlook does little to encourage such consciousness. We tend not to see individuals as being connected or dependent or the social and institutional processes to which they belong – the many for example who produce their food and clothing and other necessities while a few are training to become heart surgeons. My Seventh-Day Adventist nurse was awestruck by the complexity and integration of life on earth, which she thought could only be due to a divine creator; I am no less awestruck by the breathtaking complexity and integration of the human-created process of heart medicine. In dozens of conversations since my surgery, the word “amazing” forces its way in, used by others as well as myself to describe this life-saving system in all its aspects, all in the right place at the right time: education, nutrition, testing, diagnosis, chemicals, medications, machinery and instruments, the various forms of surgical intervention, organization down to the smallest detail. Amazing, cracking open the chest and stopping the heart to bypass clogged arteries. Amazing, the cardiac rehabilitation exercise programs that encourage and monitor the slow process of returning the heart and body to normal functioning.
Amazing: each step, striking in itself, belongs to a vast social process, replicated in hundreds of places around the country and the world. Between them all, information and techniques are shared, training and standards are developed, allowing hundreds of thousands of people to undergo life-saving and life-prolonging treatment every year.
This system has evolved over 100s and 1000s of years, although its most significant developments have come with medical and technological breakthroughs during the last 80 years: surgical repair of heart defects, catheterisation, dyes to measure blood flow and blockage, drugs to retard hemorrhage and to ease the various phases of treatment and surgery, the heart-lung machine substituting for the stopped heart during surgery, bypass surgery using the patient’s mammary artery; bypass surgery using the patient’s leg veins, transplants, angioplasty, stents. Diagnostic tools include the angiogram, the electrocardiogram, the halter monitor, the nuclear stress test, and the echocardiogram. And research has revealed vital information about the risk factors for heart disease, leading to major changes in lifestyle and nutrition. Each discovery, technique, and tool has its history, and taken together they form part of medical and thus human history.
Eighty years ago my grandfather died of a heart attack. A little over 30 years ago two of his sons, my favorite uncles, died of heart attacks. Without the last 30 years of heart technology and technique, the same would have happened to me. Today we all belong to this history and it belongs to us, shaping our possibilities. It made my heart catheterisation and angiogram an ordinary diagnostic tool, and it made open-heart surgery into a routine five-hour procedure. As dramatic as this has been for me and my family, my surgeon has performed nearly 2500 bypass operations.
Every one of us, heart patients or not, draws on this history of medical experience when we so much as take an annual physical at our doctor’s office. This history is not something external to and separate from who we are: it shapes our individual hopes and expectations – and we experience our dependence on it sometimes consciously but mostly unconsciously. Gratitude for it is a fundamental social emotion, the appreciation of one among many areas that make our lives possible.
The hospital staff, the system of heart care, its history, and indeed the history of medicine – these are some of the very specific forces I drew on during my stay in the hospital and afterwards. Of course I was, after all, fortunate that my condition was not worse, that my heart itself seemed to be strong even as my arteries were clogged, that the hospital was not jammed with heart patients that day, that my surgeon was available and in good form, that he had an excellent team of assistants, that this spare “inner-city” hospital with a large foreign-born staff and mostly black patient population had high standards of care, that my health insurance covered the diagnosis, operation, hospital stay, and follow-up treatment, including a brief but no less thorough program of cardiac rehabilitation including monitored exercise, education, and nutritional counseling.
Contemplating this carefully thought-out program while in recovery was enormously reassuring. First I would be seen regularly at home by a visiting nurse (who when necessary phoned the surgeon to resolve one of our worries), and then I’d be going into rehab. But the day before my first rehab appointment, I received a phone call that threw me into a near-panic: the insurance hadn’t approved rehab. I would have to take a stress test at the cardiologist’s – that is to say, I had to “fail” a cardiac test to confirm that I needed the exercise program, and the cardiologist had to verify that I’d benefit from it. This gatekeeping surprised both the doctor and the rehab center, and my wife and I worried that I might have recuperated too much to qualify for what we had decided was vitally necessary. It seemed to be a crazy process: still laid up, I was threatened with being completely on my own long before I felt able to be. This foolish cost control required my health insurance company to pay several hundred extra dollars. As it turned out, my heart was operating at less than 75 per cent of its previous level; I “failed” and so gained admission.
This was a slight brush with larger economic realities constraining heart care. More dramatic, the week I returned home from the hospital it was announced that the eight hospitals and other facilities of the publicly owned Detroit Medical Center would be sold to a Tennessee corporation and converted into a for-profit system. This privatization process is now complete. Who knows what changes it will bring? Already I’ve heard of demands on the staff to be “more efficient.” For-profit hospitals tend to focus on profitable services – cardiology is one of these – sometimes even ordering them when not necessary, and they tend to phase out less-profitable but no-less necessary services, such as inpatient psychiatric care and HIV/AIDS treatment.
Such thoughts carry us far from my story. But do they really? As long as I live, my survival will remain connected to the people taking care of me, to histories reaching back behind and beyond all of us, and to ever-more complex systems that cover the earth—as well as their social, political, and economic issues. Although people going through experiences such as mine sometimes frame them in terms of God and religion, my own open-heart surgery unfolded along these strictly terrestrial paths. Now that I’ve recuperated I can choose to ignore all these connections, just as I can now forget about my seven days in Sinai/Grace hospital. But even if I remain unconscious of them, in some sense they will remain part of me. The larger societal system of heart care will continue to develop, like other systems for sustaining and improving life that humans have created over time, and it will continue to be staffed by devoted people. With all its issues and question marks, it is a reason to be grateful.