Señor García’s One-Stop Shopping

“Why do you look at the speck of sawdust in your brother’s eye and pay no attention to the plank in your own eye? How can you say to your brother, ‘Let me take the speck out of your eye,’ when all the time there is a plank in your own eye? You hypocrite, first take the plank out of your own eye, and then you will see clearly to remove the speck from your brother’s eye.”

–Matthew 7:3-5

I once had a war hero sitting in my exam chair who had survived all manner of jungle ambushes but was dying from an inoperable brain tumor. He asked me a couple of questions that landed up side my head with the percussive force of an Improvised Explosive Device.

“When you examined me 2 years ago, did you see any sign that I had a brain tumor? If you had used a more extensive visual field test, could you have possibly found it?

I’d rather have been discussing the merits of a no-line bifocal versus a flat top-28, but sometimes you have to go places you don’t want to in this life. You don’t look a dying man in the eye and shoot him a bunch of BS, and I owed this one an answer.

I assured him that the kind of exam we had done two years prior was a typical “one-size-fits-all” with a standard (and clinically acceptable) visual field screener, and there had been nothing askew or unusual at the time to make me think he had a neurological time bomb ticking away in his head, and had there been, I would have gone to the wall, over the wall, and then some to find it. But if it was there and I did miss it, that I was very, very sorry. Or words to that effect.

“It’s okay, ” he said. “I’m not blaming you. I just needed to know.”

A few weeks later he was gone. His obituary in the local newspaper was longer than an Old Testament parchment scroll and filled with myriad family members, military, professional and community service accomplishments. It took up nearly two full columns.

This story, and the one to follow, aren’t the type that well-renowned and well-paid lecturers tell at continuing education meetings. In the lecture halls, everyone is Dr. Kildare (or these days, Dr. McDreamy), and all the patients get better via either a crack diagnosis or a new razzle-dazzle treatment pulled out of a hat, MacGyver style, in the heat of battle. Usually both to hear them tell it. But among the hoi polloi  in the hotel bar at night, with the lights dim and alcohol-lubricated tongues flowing more freely, the truth always comes out.

Now an occult brain tumor is nowhere near a poke in the eye with a pair of needle-nosed forceps, but don’t tell Señor García that.

He was returning to have the cataract in his left eye removed, the right one having been safely extracted at Clinica Ezell last year. He was all smiles at the prospect of his hand motion vision suddenly matching his excellent 20/40 acuity in the right eye.

We scheduled his surgery and he was on his way out the door when he stopped dead in his tracks. He started gesturing toward his right eye and chattering in rapid Spanish. I turned to my faithful translator, Danny, who was expert at taking such extended soliloquies and diatribes and condensing them into one-sentence English sound bites that even a gringo like me could understand.

“He says, ‘What about the loose sutures in my right eye?'” Danny curled up the corners of his mouth into that wry smile of his, the one that usually indicates that a lot has been lost in translation.

I sat Señor García down in the exam chair again and had him look down while I examined him with the slit lamp. In the U.S., it’s rare to see sutures anymore; most cataracts can be removed by using a small incision in the cornea that self-seals at the end of surgery.

But in Guatemala, the cataracts are often dense and hard, like a yellowed, petrified piece of plain M&M candy. An older technique with a larger wound site is usually necessary, and sometimes along with that, a single, continuous suture, woven together and crisscrossing like laces up and down the tongue of a shoe.

No problemo, Señor García, I thought.  Not only had I removed such sutures hundreds of time before, but there I was with only 2 days in country, and already I was thinking in Spanish.

I inserted a drop of topical anesthetic and grabbed my needle-nosed forceps. Lining things up just right, I slowly started to move my hand toward the exposed suture. I was confident that if I broke it somewhere in the middle, I would be able to slide the remaining ends from the scleral channel with minimal discomfort to Señor García.

What I didn’t see was that his frente wasn’t touching the head rest like I thought it was. And just as I moved my needle-nosed forceps the last little bit to grab the suture, Señor García lurched forward to meet them.

“Aieeeee!” Señor García whelped. Aye yi, yi, I thought, lapsing into Spanish-think again.

This was followed by Señor García collapsing back into the chair holding his eye, and then a spirited verbal exchange between him and Danny. It was one of those moments (and there were several on this trip) when I was thankful that I wasn’t too fluent in Spanish.

After apologizing, and with Danny’s help, I manage to calm Señor García down to the point that he actually agreed to get back into the slit lamp again. This time I managed to break the suture in half. Unfortunately, the slippery mix of reflex tears and conjunctival hemorrhage (yes, in answer to my more macabre readers, I did draw blood) made it difficult to grab on to the loose ends.

I let Señor García relax and told Number Three Son to run to the OR to fetch some more “grippy” forceps. He returned with the perfect set, broader and blunter on the end, and on the inner surface, ridges, just like the potato chip.

This time I grabbed on and the ridges took hold. I started pulling gently–or so it seemed to me.

“Aieeeee!” my patient screamed again. This was followed by more rapid-fire Spanish between him and Danny, and then a heavy, fatalistic sigh as Señor García sat back in the chair with a loud thump.

We doctors have a saying that forms the first rule of therapeutics–Primum Non Nocere. That’s Latin, not Spanish, and it means “First, Do No Harm.” I had not only broken that rule, I had nuked it. This was no management misdemeanor, but instead a full-bore, physician felony.

In other words, it’s better to leave well enough, to let bad-tempered, tick-infested, sleeping dogs lie alone under the front porch, to not rock the boat baby, to just sit on your hands and do absolutely nothing first and foremost above all else than it is to try to remove a continuous suture on the fly, in a slit lamp, with a nervous, fidgety patient who doesn’t speak your language and whose pain threshold is just a teeny-weeny bit below average.

We have another saying: hindsight is always 20/20. And with perfect clarity, I knew in that moment that it would have been much better to leave the suture in and have our ophthalmologist take it out the next day under the operating scope when Señor García had his cataract surgery done, with much less discomfort and trouble for all concerned.

Instead, now both loose ends were flopping around beneath his upper lid, irritating his eye more than ever. I asked Danny to ask him (by this time, the rest of my rudimentary Spanish had long since gone out the window) if he wouldn’t mind too awful much getting back in the slit lamp one more time so I could see what was going on and what needed to be done.

Another lively exchange later, Danny translated (mercifully, I suspect): “He says ‘Yes, as long as you don’t touch my eye.'”

Entiendo and fair enough, I thought. I gave him some ointment for his eye and told him to go sit in the waiting the area. Maybe our ophthalmologist, Dr. Coleman, could come out in between cases, take a look at him, and get that little sucker out of there once and for all.

Señor García apparently relished the idea of a second opinion. He nearly sprinted from the exam room and took his place in the waiting area, whereupon the patients who had yet to be examined were fully apprised of this new, clumsy gringo doctor and the horrific events which had taken place behind the mysterious, exam room door.

A moment later, all eyes turned toward Dr. Coleman as he rounded the corner and made his way toward Señor García. He grabbed my penlight and forceps and gave the suture a good tug. Unfortunately, he didn’t have any better luck than I had.

“Aieeeee!” came the now-familiar cry. That got the attention of everyone around him, many of whom were now no doubt thinking, Maybe I can live with this cataract after all

The best course now settled, Señor García went off to the ward to await his surgery and to try to forget about his Terrible, Horrible, No Good, Very Bad Day. “Lo Siento, Señor García,” I apologized.

“Aye, yi, yi,” Señor García grumbled in return.

Fortunately, this story has a happy ending. The next day, Señor García’s cataract popped out easier than a watermelon seed in a Fourth of July spitting contest. His sutures slid out smoothly, like a snake slithering through tall, dewy summer grass. I saw him the morning after that on rounds, approaching him from the side of his patched eye so as to, you know, not startle him.

“Buenos días, Señor García. Cómo está?”

“Muy bien, muy bien,” Señor García smiled in return. If he recognized me or my voice, he either didn’t let on or else all was forgiven.

But then his face darkened to a familiar shade of stormy, and he began to twist in his bed and reach for the covers. He tugged at his gown and exposed his swollen right knee, which was nearly as large and round as a size 3 futbol. This was followed by his customary rapid-fire Spanish soliloquy. I looked around for Danny, but he had yet to arrive.

I nodded my head in understanding, managing to convey to Señor García with exaggerated expression and pantomime that while this new problem wasn’t technically my “turf,” we did have someone who could probably help. Later that day, our orthopedic surgeon, Dr. Gilliam, drained a large amount of fluid from his knee.

Señor García never imagined in his wildest dreams that one-stop shopping could be so convenient and hassle-free.