Surgical Jenga

Surgical Jenga

The first rule is simple. The patient has to be able to stand
afterwards. He is given a maximum of seven days post-op, during which
time, he may receive such physiotherapy as can be managed. He may
support himself with crutches but must stand for thirty seconds without
falling.

That's the sentence I read, by accident, while I was trying to see
whether Dr Javier Cortez had any space to perform a lung transplant op
on Thursday.

Dr Cortez has won about half of the awards going and by all accounts is
working hard on the next half. He pioneered some revolutionary kidney
operation amongst other things. If you were to organise a reunion of
everyone whose life he had saved, you wouldn't need the Albert Hall or
the Bernebau, but somewhere that had holds a few, that's for
sure.

The last paper he'd written had been something really obscure, I
couldn't make sense of a word of it, even after four years at Medical
School. I knew I'd learn a lot from him. I had no idea how much, at the
sort of level he was operating at.

The third rule is that amputation is strictly forbidden. The limbs stay
on, people.

This wasn't the way he wrote in his medical papers. I checked the
circulation list on the email. A select number, Decker and Richmond
were there, together with a few others I had to look up later. Every
one of them a giant in their fields. Those fields all being
surgical.

Rule five. Participants must be consenting and have capacity to so
consent, on an informed basis.

What were these rules for ? Some kind of challenge between very
top-class surgeons, people who'd gone way beyond God-complex. Some game
Cortez had called "Surgical Jenga".

The second rule was that the results were to be judged by X-ray.
Independently verified and accompanied by photograph of the
patient.

I knew that there were patients in this hospital I'd never seen, even
though I was supposed to be shadowing Cortez. He would always flash me
the dimpled smile and suggest that I might like to drain Mr So-and-Sos
chest tray while he attended to one of his special patients. It didn't
matter how late I left the hospital, Cortez's car was always still
there. And it was always there in the morning.

I wondered what would drive someone like that, someone who on a weekly
basis was holding someone's heart between his fingers like a spent
balloon, tying up the complexities and bringing them home safe.

The fourth rule of Surgical Jenga was that all removals needed to take
place in one operation. This, said Cortez in the email, was the real
beauty. That balance between risking a little more and being sure that
the goods would come home to fulfill rule one. Risk, said Cortez, risk
and confidence in one's abilities, were what would win someone the
game.

After I'd read the email, I didn't know what to think. I felt sick of
course, but you build up a resistance to that in surgery. You need to
shut down the gag reflex, the conscience and think only of the surgery,
of the principles and techniques. This game might be sick, but it was
clear that it was being played by absolute masters, perhaps developing
techniques that would save lives in the future.

Rule six said, simply - each bone removed from the patient's body
scores one point. The current record is one hundred and forty-nine
points, held by Raymond Dexter of California.

I was rash to challenge Cortez about it. He looked me up and down,
before deciding that my interest was curiousity rather than outrage. He
knew I was weak, that I had no interest in going to the authorities. I
wanted to see how the work had been done, I wanted to learn.

Cortez unlocked a filing cabinet, with a key looped on a chain around
his neck. He took out a file and flipped it open. There were
photographs of a man, a patient who had been the board in this surgical
game.

There are two hundred and six bones in the human body. As Cortex pulled
out X-rays and clipped them on the light box for me to look at, I
marvelled at what he had done. He had removed one hundred and
forty-five of them.

"The feet, " he said, "Were easy. Good starting point. A man may stand
without feet. Twenty-six bones in each foot. Easy fifty-two points.
Hands, similar. "

He showed me a photograph of the patient's hand. It looked like a
glove. That sounds insane, of course it did. Gloves are shaped like
hands, all hands look a little like gloves. But this looked like a
rubber glove, saggy and formless, just an outline of how it should
look. There were no knuckles.

"Ribs, " he said, "One hundred and thirty one bones removed. Of course,
this is very much a late stage of the game. Early on, we were too bold.
We took the femur as well. Stupid. Man can't stand without femur.
"

He put an X-ray of a skull on a lightbox.

"Difficult, " he said, "Skull is very difficult. Only four bones of
twenty-two removed. I think I can do more. Dexter took four additional.
I will have to match that. One hundred and thirty-five bones removed.
Extra ten from arms. That is the best I have done. "

The man looked like a husk. Like something dried, like a sun-dried
tomato only pale.

I was learning so much from Cortez, as he showed me the notes, the
techniques he had used in this surgery, many created by himself, others
in partnership with the greatest surgeons in the world.

"How far can man be pushed ? " he said, "For me, that was the
challenge. What must remain of a man, when you can remove everything
else ? The vertebrae, we are thinking that this is a fixed point. We
cannot envisage techniques for removing any of the twenty-six bones
here. But that means the maximum score may be one hundred and eighty,
maybe a little less. "

"Do you think you'll beat Dexter ? " I asked, already vowing to play
whatever part I could.

"One fifty-five, " he said with triumph, "That is target for next
surgery. I have been practising, developing my skills. I think I can
match Dexter in the skull and find six bones he has overlooked. "

That seemed impossible. What more could be removed from a man in a
single piece of surgery and have him still live and be able to stand,
with aid only of crutches for thirty seconds ?

Cortex gave his ear lobe a little tug, "Stirrup, hammer, anvil. Six
little tiny bones. "