My commute had to rank as one of the most beautiful drives to work one could have. Our house stood some four blocks from the beach in San Francisco. Unlike San Diego, this more northern city’s waterline touches frigid water, where ten foot waves are not uncommon, and winds that feel like powdered ice blow over the fawn-colored sand. The sand itself, sad to say, never seemed too clean in those days. Beach dwellers included homeless kids burning bonfires, legions of dog walkers who did not care that their pets were polluting the shore, and picnickers who ‘forget’ to walk their trash back to the parking lots. Still, from our bedroom window the ocean had a rumbling majesty that mesmerized me. In the mornings I stood in front of the open frame, felt the chilled, salted air sweep in, and listened to the ceaseless rhythm of the waves massaging the broad plain of sand.
After I finished my brief coffee break before the window, I strapped myself into my recently-purchased Volvo, backed out of the garage onto the gridwork of San Francisco streets, and made my way toward Marin County. The car had been an expensive effort to help my neck. I thought perhaps the ‘advanced ergonomics’ might help lessen the pain that had become my regular travel companion on my drives home. These trips sometimes seemed endless as I sat stiffly behind the wheel, locked into a rigid posture by the growling ache that spread from the base of my skull halfway down my back. In the mornings, however, the discomfort could almost be forgotten. Just a line of arthritic throbbing in the depths of my neck. My mind had become adept at tuning that lesser discomfort out, so I could take in the scenery along the drive to work.
After less than a mile I drove into Lincoln Park, where the road skirts the cliffs above the mouth of San Francisco Bay. In the mornings, often, the water color was halfway between slate gray and navy blue. The Golden Gate Bridge stretched north across the channel with its art deco elegance, painted the color or an old, rusted nail laying in the sun. My drive exited the park and took me through the Sea Cliff neighborhood, home to the very wealthy. Robin Williams has a home there, with topiary dinosaurs and a wall of rooms facing the ocean. I drove past it every day, and always smiled at the sight of the brontosaurus arching its neck above the pink stucco wall that surrounds the property. Sea Cliff ends at the Presidio, the former army base long since converted to civilian use. The road then winds along the bluffs above Baker Beach (shown in the photo with this post), where you can sunbathe in the nude if weather and your own modesty permit. The views of the sage-covered hills shimmering in the morning sun, with traces of mist still visible in the wind-sculpted cypress trees, made me feel infinitely fortunate to be able to drive this way so often. From the Presidio my route took me over the bridge. The sun glinted in my eyes as it burned low and golden over the hunched mountains above Berkeley on the eastern side of the bay, a dozen miles or so across the water. Squinting into the light, I could just make out the University of California bell tower as a square white obelisk silhouetted against the hillside. At age twenty I had spent an afternoon atop it, during the short span of time when there were no bars or plastic screens stopping jumpers, and tried to decide if things were bad enough to take the plunge. On glorious mornings such as this, I felt profoundly grateful to my young self for giving life another chance.
Sadly, by the afternoon, I felt irritated at that young man for prolonging the agony.
***
I thought about my morning commute as I pulled off my baby-blue paper operating gown and blood splattered sterile gloves at the end of the last case of the day. My neck screamed with a galaxy of aches, stabbing sensations, burning and throbs. It was a kaleidoscope of discomfort that made me hunch my shoulders and involuntarily reach my hand to the back of my neck and grip it as tightly as I could. At least the pain that movement created felt like it was under my control, unlike the stinging hail of torments that my neck had been showering on my psyche for the past hour. The case had been uncomplicated. A simple reconstruction of a lower eyelid and part of the cheek following excision of a large skin cancer. Under better circumstances, such cases were my favorite occupation. They each had some element that was unlike the dozens or hundreds of previous lid rebuilds that might have looked identical to the casual eye. Decisions had to be made about how best to restore a nice appearance and comfortable position and function to the eyelid. Done well, and the person would look like little if anything had happened (after the year or more that it took for the scars to fade), and their eye would be as comfortable as ever. Done badly, and the lid would shrink away from the surface of the globe, imparting an angry and deformed look to the area, and making the patient feel as if a teaspoon of sand had blown into the eye, with all the inflammation and tearing you would expect. So the stakes were not low, and the work required creative thought and dextrous finesse. I loved such work.
Normally. Normally, I loved such work. But when my neck intruded with its complaints, as it did more and more often these days, the work became a Dante-esque torment. The ruptured discs and all the other problems hurt so much, so insistently, that all I wanted to do was run out of the operating suite, grab an ice pack, and go lay down in a dark room. But of course I could not. So I did my best to ignore the mallet pounding at the base of my skull, and the hot spikes in my shoulders. I tried to proceed just the same as always, even as the neck pain started to ignite a migraine headache with its attendant lurching nausea. Sometimes, like today, it became more than I could bear.
There are times in reconstructive surgery, in all surgery, when you have to make decisions about whether to stop now, or take on another task to try to perfect the outcome. It might be deciding whether to let an area heal in on its own (’granulate’ in technical terms), or cover it with a skin graft. The answers are seldom black and white. There are pluses and minuses each way. Every additional step brings an added chance of complication. The graft might die from inadequate blood supply, for instance. The added stage also increases the area involved by the surgery, and hence the post operative pain. But, using the skin graft example, it might speed healing and improve appearance. So you face this kind of decision, and you make your choice in the best interest of the patient.
But on this day I did not. My neck pain was so intense, the headache so oppressive, that I just could not imagine adding the extra forty-five minutes to the procedure that a skin graft would require. So I stopped. I pulled off my soiled gloves, covered the incision lines with antibiotic ointment, and dressed the site in fresh gauze. I scribbled a few notes. I neglected to talk to the waiting family, and instead rushed to my office, head down so no one would catch my eye and ask me for any help. I was desperate to press a chemical ice pack against my neck (the kind you crush to activate). All I could think about was getting the hammering pain from my degenerated disc spaces to settle down.
Ten minutes later things had calmed. The pain had backed off from 9.5 on a scale of 10 to something more like a seven. My breathing slowed, the nausea eased, the stars quit swimming across my field of view. Stopping the operation always helped the pain. Something about the huddled posture over the operating table, the tension in my arms and shoulders, the hot, bright lights, and the long periods of barely moving triggered excruciating reactions. These spasms of unspeakable discomfort always abated once I was able to stand up straight, relax my body, get to a cool location, and do some stretches. The problem was, I could never do that until the procedure had been properly completed, and the patient tucked safely into the recovery room.
That night, driving south toward the bridge. I thought more seriously than ever about parking in the lot at the north side of the channel. They had remodeled the area not long before, with a nice promenade lined by a stone wall, that offered postcard views of the orange-red span and San Francisco. A truly beautiful location, but to me it symbolized a portal out of the agony of this world. I could have parked, strolled south on the sidewalk over the bridge, and leaped over the retaining rail somewhere more or less half-way across (you could not jump at the exact mid-point, because the suspension cable connected with the bridge platform at that spot. I always had to ask whether I would plunge before I reached that point, or after I passed it. Such details seemed important, even though the end result would be the same lethal collision with the freezing water 220 feet (67 m) below.)
Obviously, I did not stop, did not park, did not jump. But in a way, my life still ended on that day. I knew I could not continue performing operations. I had consulted with neurosurgeons about my neck, and there was so much pathology that the surgery required would be extensive, not terribly likely to help, and would only be a temporary fix even if it did. What’s more, just quitting surgery would not be enough. I would not even be able to go back to general ophthalmology. In theory, I might have been able to treat glaucoma and other problems that could be managed with eye drops, as long as I stayed out of the operating room. But that still meant contorting my body to see through the ophthalmic instruments. Eye doctors have high rates of neck and back disability even if they don’t spend three days a week operating, as I had. Going back to rolling around on a little stool, cramping up against the ’slit lamp’ and hunching over patients to see their retinas would not work. I was going to have to leave ophthalmology altogether, not just the ophthalmic plastic surgery that was my subspecialty.
The evening light began to look dreamlike. I felt an odd mix of terror and euphoria. My heart pounded with fear, but also with relief since I had finally decided to quit forcing myself to endure such torment. For years I had fought to manage the problem. I had bought new chairs for both my office and my desk at home, and battled (unsuccessfully) to get the hospital to invest in lightweight head gear and a better operating table for me. I persuaded the nurses to inject me, between cases, with powerful non-steroidal anti-inflammatory drugs to help alleviate the pain. I got weekly massages and was diligent about stretches and every exercise that, according to the physical therapists, would help my neck. Nothing had worked. On this night, as I completed the most gorgeous commute in the world for one of the last times, I knew the war was over. I had lost, but at least the carpet bombing would cease.
By the time I pulled into the garage above which our over-sized San Francisco row house was built, the blue had drained from the sky. One or two of the brightest stars were visible despite the early hour, the city glare, and the ocean mist. Moving slowly and uncomfortably, I worked my way out of the shiny green Volvo that I had purchased, at great expense, in the desperate hope that it would help me keep my job. I turned off the garage light, and climbed the two flights of stairs to the main floor. Without searching out my wife, I walked to the bedroom and stood before the window with its stunning ocean view. I listened to the relentless breakers slamming their open fists into the sand. At the same time, without thinking, I tried to massage away the pain in my trapezius muscles using clenched hands. I thought of how long and strenuously I’d worked to get to this point in my life. The hard-studying years in college, graduate school, and medical school. The six years of post-doctoral training, with the absurd hours and mammoth workload. The years on the job getting to a point of confidence and comfort as a full fledged doctor in practice. I thought of all I’d won: the respected position as an ocular plastic surgeon and ocular oncologist, the beautiful San Francisco house with its ocean view, a good income with lifetime benefits. Although I could not see the future clearly, I knew this was all over. On one level, I still had confidence in my ability to pull together another line of work with equal pay and status. But on a deeper level, I felt the end approaching with the same certainty as the gathering darkness outside.
As I stood before the open glass, I felt the wet, salty air on my face. I could see more stars now. The haze had thinned, and the sky had blackened. These were not the virgin skies of pre-civilization, before electric lights and air pollution. The atmosphere, like my neck, had been pushed too hard and bruised. But I saw enough far-off suns to appreciate the hopefulness of their sparkle over the inky ocean horizon, as I listened to the measured and nearly organic pulse of the waves combing the shore. I turned away from the window, and went to find Mandy. With the backs of my hands, I wiped the moisture from both cheeks. My decision to abandon my career would upset her. I would try to make it sound like a positive step, but she would not be fooled. She would recognize that I was stepping onto an unstable bridge to somewhere unknown, and that the chances of finding an opposite shore as safe and comfortable as this one were slim. I could not conceal the danger, but at least I could hide my tears.
(I modified the wording of this post, 7 September 2009, c. 07:35 PDT.)
