The Clamp Incident: On Therapy in Modern Medicine

Posted on by Xavier Muller

by X. Muller

Lyon, France, Croix Rousse University Hospital, 1 AM, February 10, 2023. *

Three hours into the surgery, I placed the surgical clamp on the upper part of the vena cava, the large vein carrying the deoxygenated blood from the lower body to the right atrium of the heart. This was the last mandatory step before the veins of the liver could be safely divided just above the clamp in order to remove the diseased organ from the abdominal cavity of the patient. The role of the clamp was to firmly close the large hole left in the vena cava after the liver was removed, hereby preventing the occurrence of a fatal bleeding. This allowed to move on to the implantation of the liver graft, which had been procured from a deceased organ donor several hours ago. The implantation is the final phase of a liver transplantation where the three major blood vessels and the bile duct of the graft are reconnected to those of the recipient by manual sutures.

Liver transplantation has come a long way since the first successful procedure in 1963.1 From a technical point of view, the procedure is now well standardized and offers patients with end-stage liver disease the only live saving treatment.2 In addition, recent scientific advances have allowed more patients to gain access to liver transplantation, for example the use of immunotherapy for advanced liver tumors. Technically and scientifically speaking, liver transplantation, it always occurred to me, has been a success story, and the procedure on that given day in February was part of that story.

Until the clamp on the vena cava slipped!

I heard the voice of the scrub nurse yelling in French “Mon Dieu, we have a major bleeding.” My colleague, in what was more a muscle memory reflex than a conscious decision, used his left hand to compress the vena cava above the hole left by the slipped clamp and placed a second clamp on the vena cava just below the hole in order to stop the bleeding. Instantly, we heard the nervous beeping of the patient monitor indicating low blood pressure. “Can you relieve the clamp in order to restore the blood return into the right atrium of the heart?” asked the anaesthesiologist. “Negative, we need to implant the liver graft with both clamps in place. You need to hold the blood pressure for at least 40 minutes!”, my colleague replied while placing the graft in the patient’s abdomen to start the implantation. At this point, it was clear to everyone in the room that what had been a routine liver transplantation with minimal blood loss and no technical difficulties, now became a challenge to get the patient out of the operating room alive.

When I visited the patient on the intensive care unit after the successful transplantation, at once he asked me if everything went according to plan. “Not exactly. We had a clamp incident.” Then, I told him the entire story. I emphasized that it was due to the experience of the whole team that we were able to safely complete the liver transplantation, despite the unexpected event. “Will this change anything for me?”, he asked. “For now, the liver graft is working fine, but we have to take it day by day from here.” After leaving his room I glanced back, and I could see in his eyes that he was starting to process what I had just told him. Although he had been under general anaesthesia during the surgery, I felt as if we had engaged in a very close bond during the clamp incident. Suddenly, I also remembered that we had briefly discussed the potentially fatal outcome of a liver transplantation in the routine pre-transplant consultation. I had specifically pointed out that dissecting a major blood vessel such as the vena cava exposes to a risk of bleeding and death. At that time, none of us knew of course that we would be confronted to exactly this situation.

The more I thought about the incident, the more I wondered how to situate the latter in the broader scope of modern medical practice. What struck me most, was how this singular experience was different from what I was taught in medical school and what was now expected from me as an academic surgeon. For example, during my PhD thesis, I worked on optimizing the preservation of liver grafts prior to transplantation in an experimental swine model.3 The endpoint of the study was to quantify and compare the metabolic and cellular changes in the liver graft during different preservation strategies. In other words, the methodological framework applied here is that of medical science, that is, based on a given clinical observation, for instance a disease, a theoretical hypothesis is tested in a confined and controlled experimental setting. So far so good. But what I couldn’t get my mind around, was that all that theoretical knowledge obtained through medical science, was of little help on that given day in February. In other words, notwithstanding all the scans, MRIs, blood screenings and treatments of the patient, it all came down to a simple surgical clamp: for me, the patient, the scrub-nurse and all the people directly involved in the therapy of the patient.

Therapy! Exactly, that was it. Once arrived at home, I grabbed the books by the French philosopher Georges Canguilhem, who was recommended to me by a friend following a discussion on therapy in medicine. I had struggled to grasp what exactly Canguilhem wanted to tell his readers. Yet, now, after what had happened in the operating room, the passages in his works became clearer. For what I realized what the precariousness and singularity of life that Canguilhem writes about, was really about.

“Diseases are crises …” in the life of an individual, the philosopher writes.4 They “are felt by the living as a harm, an evil.”4 Therefore, death has to be situated “in life—and disease is the sign of this.”4 Death is not an abstraction, somewhere out there, it has a daily presence when confronting sick patients. But more than that, for the patient these signs of illness, these “diseases are not only limitations of his physical power, they are the dramas of his history. Human life is an existence […] and is haunted by its end.”5 The slip of the clamp brought that end a good deal closer, and even though the patient was anesthetized, he and everybody involved felt exactly what drama meant. In that moment, the patient’s life not only became a singular event, undistinguishable from any other, moreover the patient emerged as a whole individual, with whom I had agreed on conducting an operation as well as to care for after. That’s what therapy is about: the process through pre-, intra- and post-operative phases.

This brings us to the central question for Canguilhem: “the problem of individuality” in disease.6 Given that it is the patient as an individual who is sick, I as a physician engaging in therapy, cease to be a simple “repairer” of sick organs.7 For Canguilhem it is “incorrect to speak of diseased organs, diseased tissues, diseased cells”5 Sickness cannot be dissociated from the person as a whole. Clinical “practice puts the physician in contact with complete and concrete individuals and not with organs and their functions.”6 Disease affects the entire organism because the parts of the organism cannot be isolated atomically from one another – even if my own practice, liver transplantation, consists in exchanging an isolated organ. Disease as the “drama” of the patient’s personal “history” became my drama, and I realized this through the clamp incident.

If I am not just a repairer operating according to standardized procedures, then surgery is not just about standardization, quantification or objectivity. Consequently, medical therapy cannot be reduced to mere scientific endeavour. Indeed, medicine exists “because there are men who feel sick, not because there are doctors to tell men of their illnesses.”6 In other words, the “doctor is called by the patient.”6 Science is helpful in treating patients, but it remains a tool, just like the clamp, in the context of a patient-doctor relationship. This relationship goes well beyond the notion of a dysfunctioning organ. Medicine is “a technique or art at the crossroads of several sciences, rather than, strictly speaking, like one science.”6 When I transplant livers, I am not conducting experiments as part of medical science. Patients are not subjects of an experiment with the primary aim of gaining theoretical knowledge. Their body is not “passive and obedient to external manipulations and solicitations.”7 The physician is not just a blind repairer, but an “exegete” who interprets signs that the patient as a whole individual is communicating.8

Although I have thought to be a surgeon-scientist in a highly specialized and standardized field of medicine, I now recognize that therapy needs to grasp the singularity of each individual patient. This singularity is the basis, and yet, also the limit of therapeutic activity in medicine. A single clamp, beyond every statistical approximation. Despite over 10 years of medical studies, the clamp incident taught me what it takes to become a therapist in modern medicine. The hard way.

*Date and time as well as identifying details have been changed to ensure anonymity.

Acknowledgements

I would like to thank the entire surgical team including the anesthesiologists and the scrub nurses. Special thanks to Guillaume Rossignol who was one of the 2 surgeons involved in the procedure .

References

  1. Starzl Te, Marchhioro Tl, Vonkaulla Kn, Hermann G, Brittain Rs, Waddell Wr. Homotransplantation of the liver in humans. Surg Gynecol Obstet. 1963; 117:659-676.
  2. Lucey MR, Furuya KN, Foley DP. Liver Transplantation. N Engl J Med. 2023;389(20):1888-1900. doi:10.1056/NEJMra2200923
  3. Muller X, Rossignol G, Couillerot J, et al. A Single Preservation Solution for Static Cold Storage and Hypothermic Oxygenated Perfusion of Marginal Liver Grafts: A Preclinical Study. Transplantation. 2024;108(1):175-183. doi:10.1097/TP.0000000000004714
  4. Canguilhem, G., Diseases, in: Writings on Medicine, translated by Stefanos Geroulanos and Todd Meyers, Fordham University Pres, New York, 2012, p. 34-42.
  5. Canguilhem, G. Is a Pedagogy of Healing Possible? in: Writings on Medicine, translated by Stefanos Geroulanos and Todd Meyers, Fordham University Pres, New York, 2012, p. 53-66.
  6. Canguilhem G., The Normal and the Pathological, translated by Carolyn R. Fawcett, Zone Books, New York, 1991.
  7. Canguilhem, G., The Idea of Nature in Medical Theory and Practice, in: Writings on Medicine, translated by Stefanos Geroulanos and Todd Meyers, Fordham University Pres, New York, 2012, p. 25-33.
  8. Canguilhem, G., Health: Popular Concept and Philosophical Question, in: Writings on Medicine, translated by Stefanos Geroulanos and Todd Meyers, Fordham University Pres, New York, 2012, p. 43-52.