Authors: Atul Gawande
On January 14, 1999, Christine Drury and her father arrived in Göteborg. The city is a four-hundred-year-old seaport on Sweden’s southwest coast, and she remembers the day as cold, snowy, and
beautiful. The Carlanderska Medical Center was old and small, with ivy-covered walls and big, arched wooden double doors. Inside, it was dim and silent; Drury was reminded of a dungeon. Only now did she become apprehensive, wondering what she was doing here, nine thousand miles away from home, at a hospital that she knew almost nothing about. Still, she checked in, and a nurse drew her blood for routine lab tests, made sure her medical records were in order, and took her payment, which came to six thousand dollars. Drury put it on a credit card.
The hospital room was reassuringly clean and modern, with white linens and blue blankets. Christer Drott, her surgeon, came to see her early the next morning. He spoke with impeccable British-accented English and was, she said, exceedingly comforting: “He holds your hand and is so compassionate. Those doctors have seen thousands of these cases. I just loved him.”
At nine-thirty that morning, an orderly came to get her for the operation. “We had just done a story about a kid who died because the anesthesiologist had fallen asleep,” Drury says. “So I made sure to ask the anesthesiologist not to fall asleep and let me die. He kind of laughed and said, ‘OK.’ ”
While Drury was unconscious, Drott, in scrubs and sterile gown, swabbed her chest and axillae (underarms) with antiseptic and laid down sterile drapes so that only her axillae were exposed. After feeling for a space between the ribs in her left axilla, he made a seven-millimeter puncture with the tip of his scalpel, then pushed a large-bore needle through the hole and into her chest. Two liters of carbon dioxide were pumped in through the needle, pushing her left lung downward and out of the way. Then Drott inserted a resectoscope, a long metal tube fitted with an eyepiece, fiber-optic illumination, and a cauterizing tip. It is actually a urological instrument, thin enough to pass through the urethra (though never thin enough, of course, for urology patients). Looking through the lens, he searched for her left sympathetic trunk, taking care to avoid injuring the main blood vessels from her heart, and found the glabrous, cordlike
structure lying along the heads of her ribs, where they join the spine. He cauterized the trunk at two points, over the second and third ribs, destroying all the facial branches except those that lead to the eye. Then, after making sure there was no bleeding, he pulled the instrument out, inserted a catheter to suction out the carbon dioxide and let her lung re-expand, and sutured the quarter-inch incision. Moving to the other side of the table, he performed the same procedure on the right side of her chest. Everything went without a hitch. The operation took just twenty minutes.
What happens when you take away a person’s ability to blush? Is it merely a surgical version of Merle Norman Cover Up Green—removing the redness but not the self-consciousness? Or can a few snips of peripheral nerve fibers actually affect the individual herself? I remember once, as a teenager, buying mirrored sunglasses. I lost them within a few weeks, but when I had them on I found myself staring at people brazenly, acting a little tougher. I felt disguised behind those glasses, less exposed, somehow freer. Would the surgery be something like that?
Almost two years after Drury’s operation, I had lunch with her at a sports bar in Indianapolis. I had been wondering what her face would look like without the nerves that are meant to control its coloring—would she look ashen, blotchy, unnatural in some way? In fact, her face is clear and slightly pinkish, no different, she said, from before. Yet, since the surgery, she has not blushed. Occasionally, almost randomly, she has experienced a phantom blush: a distinct feeling that she is blushing even though she is not. I asked if her face reddens when she runs, and she said no, although it will if she stands on her head. The other physical changes seemed minor to her. The most noticeable thing, she said, was that neither her face nor her arms sweat now and her stomach, back, and legs sweat much more than they used to, though not enough to bother her. The scars, tiny to begin with, have completely disappeared.
From the first morning after the operation, Drury says, she felt transformed. An attractive male nurse came to take her blood pressure. Ordinarily, she would have blushed the instant he approached. But nothing of the sort happened. She felt, she says, as if a mask had been removed.
That day, after being discharged, she put herself to the test, asking random people on the street for directions, a situation that had invariably caused her to redden. Now, as her father confirmed, she didn’t. What’s more, the encounters felt easy and ordinary, without a glimmer of her old self-consciousness. At the airport, she recalls, she and her father were waiting in a long check-in line and she couldn’t find her passport. “So I just dumped my purse out onto the floor and started looking for it, and it occurred to me that I was doing this—and I wasn’t mortified,” she says. “I looked up at my dad and just started crying.”
Back home, the world seemed new. Attention now felt uncomplicated, unfrightening. Her usual internal monologue when talking to people (“Please don’t blush, please don’t blush, oh God I’m going to blush”) vanished, and she found that she could listen to others better. She could look at them longer, too, without the urge to avert her gaze. (In fact, she had to teach herself not to stare.)
Five days after the surgery, Drury was back at the anchor desk. She put on almost no makeup that night. She wore a navy-blue woolen blazer, the kind of warm clothing she would never have worn before. “My attitude was, This is my debut,” she told me. “And it went perfectly.”
Later, I viewed some tapes of her broadcasts from the first weeks after the surgery. I saw her report on the killing of a local pastor by a drunk driver, and on the shooting of a nineteen-year-old by a sixteen-year-old. She was more natural than she’d ever been. One broadcast in particular struck me. It was not her regular nighttime bulletin but a public-service segment called “Read, Indiana, Read!” For six minutes of live airtime on a February morning, she was shown reading a
story to a crowd of obstreperous eight-year-olds as messages encouraging parents to read to their children scrolled by. Despite the chaos of kids walking by, throwing things, putting their faces up to the camera, she persevered, remaining composed the entire time.
Drury had told no one about the operation, but people at work immediately noticed a difference in her. I spoke to a producer at her station who said, “She just told me she was going on a trip with her dad, but when she came back and I saw her on TV again, I said, ‘Christine! That was unbelievable!’ She looked amazingly comfortable in front of the camera. You could see the confidence coming through the TV, which was completely different from before.” Within months, Drury got a job as a prime-time on-air reporter at another station.
A few snips of fibers to her face and she was changed. It’s an odd notion, because we think of our essential self as being distinct from such corporeal details. Who hasn’t seen a photo of himself, or heard his voice on tape, and thought, That isn’t me! Burn patients who see themselves in a mirror for the first time—to take an extreme example—typically feel alien from their appearance. And yet they do not merely “get used” to it; their new skin changes them. It alters how they relate to people, what they expect of others, how they see themselves in others’ eyes. A burn-ward nurse once told me that the secure may become fearful and bitter, the weak jut-jawed “survivors.” Similarly, Drury had experienced her trip-wire blushing as something entirely external, not unlike a burn—“the red mask,” she called it. Yet it reached so deep inside her that she believed it prevented her from being the person she was meant to be. Once the mask was removed, she seemed new, bold, “completely different from before.” But what of the person who all her life had been made embarrassed and self-conscious at the slightest scrutiny? That person, Drury gradually discovered, was still there.
One night, she went out to dinner with a friend and decided to tell him about the operation. He was the first person outside her
family she had told, and he was horrified. She’d had an operation to
eliminate her ability to blush?
It seemed warped, he said, and, worse, vain. “You TV people will do anything to improve your career prospects,” she recalls him saying.
She went home in tears, angry but also mortified, wondering whether it
was
a freakish and weak thing to have done. In later weeks and months, she became more and more convinced that her surgical solution made her a sort of impostor. “The operation had cleared my path to be the journalist I was trained to be,” she says, “but I felt incredibly ashamed over needing to remove my difficulties by such artificial means.”
She became increasingly fearful that others would find out about the operation. Once, a coworker, trying to figure out what exactly seemed different about her, asked her if she had lost weight. Smiling weakly, she told him no, and said nothing more. “I remember going to a station picnic the Saturday before the Indy 500, and thinking to myself the whole time, Please, please let me get out of here without anyone saying, ‘Hey, what happened to your blushing?’ ” It was, she found, precisely the same embarrassment as before, only now it stemmed not from blushing but from its absence.
On television, self-consciousness began to distract her again. In June of 1999, she took up her new job, but she was not scheduled to go on the air for two months. During the hiatus, she grew uncertain about going back on TV. One day that summer, she went out with a crew that was covering storm damage in a neighboring town where trees had been uprooted. They let her practice her standup before the camera. She is sure she looked fine, but that wasn’t how she felt. “I felt like I didn’t belong there, didn’t deserve to be there,” she says. A few days later, she resigned.
More than a year has passed since then, and Drury has had to spend this time getting her life back on track. Unemployed and ashamed, she withdrew, saw no one, and spent her days watching TV from her couch, in a state of growing depression. Matters changed for her only gradually. She began, against all her instincts, admitting
to friends and then former coworkers what had happened. To her surprise and relief, nearly everyone was supportive. In September 1999, she even started an organization, the Red Mask Foundation, to spread information about chronic blushing and to provide a community for its sufferers. Revealing her secret seemed to allow her finally to move on.
That winter, she found a new job—in radio, this time, which made perfect sense. She became the assistant bureau chief for Metro Networks radio in Indianapolis. She could be heard anchoring the news every weekday morning on two radio stations, and then doing the afternoon traffic report for these and several other stations. Last spring, having regained her confidence, she began contacting television stations. The local Fox station agreed to let her be a substitute broadcaster. In early July, she was called in at the last minute to cover traffic on its three-hour morning show.
I got to watch the show on tape. It was one of those breakfast news programs with two chirpy co-anchors—a man and a woman—in overstuffed chairs, cradling giant coffee mugs. Every half hour or so, they’d turn to Drury for a two-minute traffic report. She’d stand before a series of projected city maps, clicking through them and describing the various car accidents and construction roadblocks to look out for. Now and then, the co-anchors would strike up some hey-you’re-not-our-usual-traffic-gal banter, which she managed comfortably, laughing and joking. It was exciting, she says, but not easy. She could not help feeling a little self-conscious, wondering what people might think about her coming back after her long absence. But the feelings did not overwhelm her. She is, she says, beginning to feel comfortable in her own skin.
One wants to know whether, in the end, her troubles were physical or psychological. But it is a question as impossible to answer as whether a blush is physical or mental—or, for that matter, whether a person is. Everyone is both, inseparable even by a surgeon’s blade. I have asked Drury if she has any regrets about the operation. “Not at all,” she says. She even calls the surgery “my cure.” At the same time,
she adds, “People need to know—surgery isn’t the end of it.” She has now reached what she describes as a happy medium. She is free from much of the intense self-consciousness that her blushing provoked, but she accepts the fact that she will never be entirely rid of it. In October, she became a freelance part-time on-air reporter for Channel 6, the ABC television affiliate in Indianapolis. She hopes the job will become full-time.
A
Roux-en-Y gastric-bypass operation is a radical procedure and the most drastic means available to lose weight. It is also the strangest operation I have ever participated in in surgery. It removes no disease, repairs no defect or injury. It is an operation that is intended to control a person’s will—to manipulate a person’s innards so that he will not overeat again. And it is soaring in popularity. Some 45,000 obesity patients had gastric-bypass surgery in the United States in 1999, and this number is on its way to doubling by 2003. Vincent Caselli was about to join them.
At 7:30
A.M.
on September 13, 1999, an anesthesiologist and two orderlies brought Caselli (whose name has been changed) into the operating room where I and his attending surgeon awaited him. Caselli was fifty-four years old, a heavy-machine operator and road construction contractor (he and his men had paved a rotary in my own neighborhood), the son of Italian immigrants, a husband of thirty-five years, and a father to three girls, all grown now with children of their
own. He
also weighed four hundred and twenty-eight pounds, though he stood just five feet seven inches tall, and he was miserable. Housebound, his health failing, he no longer had anything resembling a normal life.