Her left hand
A surgeon’s journey back
As the mental fog from the surgery began to lift, surgeon Sherry Wren asked a friend visiting at her bedside for a dab of lip moisturizer. Her lips were dry, as is common after surgery.
“I took it with my right hand,” Wren says. “I could move my hand, but I could not find my face.” Her right hand with the drop of petroleum jelly headed for her chin, completely missing her lips. Her friend had to help. The two chuckled, assuming that it was the anesthesia, that she was still a bit drugged up. Everything’s fine. Everything’s fine, she thinks. The spinal cord surgery, a roughly 90-minute procedure on the morning of June 29, 2012, went well. Except, why can’t my hand find my lips? And my left hand, why can’t I move it yet?
From the Stanford operating room, Wren, 53, professor of surgery and associate dean for academic affairs at the Stanford School of Medicine, had been moved to the post-anesthesia care unit. The searing pain of the previous three weeks was mercifully gone. The neurosurgeon had entered through the front of Wren’s neck to fuse two vertebrae and remove a ruptured disc. Her family and friends blamed the disc injury on a high-seas shipwreck three weeks earlier, but she wasn’t so sure. Wren had been one of 26 tourists and crew who abandoned a sinking diving yacht in rough seas 15 miles off the coast of Layang-Layang Island, Malaysia. All of them survived by navigating motorized rafts to shore.
In the post-anesthesia care unit the morning after her surgery, Wren next remembered the nurse coming in to check her motor functions. About then, the fog lifted, and she began to think more clearly. “My left hand was like a claw. I couldn’t lift my left knee. Then my surgeon came to see me, and I recognized that ‘Oh shit!’ look on his face, because I’ve had that ‘Oh shit!’ look many times.”
Wren, who has operated on hundreds of patients herself over nearly three decades, who has prepared so many others for the possibility of post-surgical complications, who has made it ever so clear that no surgery is risk free. This time, she’s the one with odds in her favor but who still loses the roll of the dice.
It was the correct diagnosis. The correct treatment. There was no surgical error. And yet somehow, the veteran surgeon who makes a living with her hands woke up partially paralyzed. The unexpected complications included paralysis of her left hand and her left leg, and a weakened right hand. Already she thinks, Will I still be able to operate? Already she thinks, What am I if I’m not a surgeon?
“Look, something can always go wrong. I’m the poster child for that,” she says, telling the story almost two years later, sitting at her desk in her office at the Veterans Affairs Palo Alto Health Care System. “I see a lot of patients. I tell them what the ‘percentage of chance’ is for a certain complication, but that’s pretty much meaningless. Sometimes stuff just happens that you can’t predict. I am the person who really understands that. I’m the one case in a million that went wrong.”
Three weeks prior to her spine surgery, Wren had awoken at 3 a.m. in her bed after the 24-hour journey home to Palo Alto from Malaysia and started diagnosing herself. What could cause this crushing chest pain that radiates out my back? Aortic dissection? A heart attack?
The shipwreck had occurred during one of her many deep-sea diving vacations. The 130-foot yacht, the Oriental Siren, started taking on water while most passengers and crew were asleep in the early hours of June 8, 2012. At 4 a.m., a crew member knocked on cabin doors yelling: “Muster with your life jackets!”
“I never thought I’d hear that,” Wren says. “I knew it was serious.” The boat was taking on water in the rear, but the crew didn’t know from where. They were setting up an auxiliary pump because the main one was damaged and irreparable.
Two hours later, the power went out on board, and the crew could no longer steer the boat as it rocked and rolled through 15-foot swells. The decision to abandon ship was made at 7 a.m., and all 26 passengers and crew climbed into the two rafts.
“The Thai captain, who couldn’t speak English, was curled up in the fetal position in the front of one of the life rafts,” Wren says. “He had totally checked out. So it was the dive masters and the passengers who had to make the decisions. Some people did start to lose it.” With no response from the Malaysian navy to the crew’s mayday radio calls, the survivors decided to make their own way to the bits of land visible between ocean swells. All 26 made it. All survived.
“Shipwreck almost over!!!” Wren posted on Facebook once she made it to shore. “Still can’t believe all my gear and stuff is 6,000 ft. below the ocean.”
The survivors spent the night in the lone hotel on the island then hopscotched across Asia to get home. Wren’s trip involved five connecting flights, with a particularly long layover in the Narita airport in Japan.
She’s still not sure what caused the horrible pain. Maybe it was the strenuous two hours spent in the rescue craft. Wren stepped in to help refill the outboard engine’s tank, lifting heavy gas cans as the craft crashed through those 15-foot swells. Or maybe it was the six-hour layover in Narita where she slept upright in a chair, her head drooping. Or maybe it was just an accumulation of damage from the many years she has spent standing up on a stool in the operating room so that her 5-foot, 3-inch frame could bend over and she could tilt her head down to see inside her patients’ abdomens as she cut and sutured and toiled to save their lives.
Whatever the cause, the pain that ripped through her chest was so excruciating she was forced to wake her husband. He wanted to rush her to the emergency room right away, but she held out until 7 a.m. — advice she would never give anyone else. “No one wants to be seen naked in front of their friends at work,” she says.
At the Stanford ER, the potential diagnoses came and went until finally someone suggested nerve damage and the neurologist arrived to examine her. There were more tests, more speculations, then somewhat randomly, the medical staff started flicking the middle finger on each of her hands.
“I’m thinking ‘What the heck?’” she says. She had tested positive for the Hoffman’s reflex test, apparently rarely seen. When the middle finger is flicked and the last joint of the thumb flexes at the same time, this indicates problems in the nerve system of the spine. The diagnosis: acute spinal cord compression. A spinal disc herniation was bulging onto the spinal cord, flattening it like a ribbon. The solution: surgical removal of the bulging disc and fusion of vertebrae 5 and 6, and 6 and 7.
For the next three weeks while waiting for surgery, she slept sitting up to control the pain. When the day of surgery finally arrived, the pain was so unbearable that the surgical team had to knock her out with medication before she could be laid flat on the operating table. Perhaps that’s when the complications occurred — the damaged disc bulging just the right way, putting pressure on the nerves just the wrong way.
A surgeon’s life
If surgeons have a stereotype, which they do of course, Wren fits much of the bill: tough, fearless, strong, impatient, efficient. Her specialty as a professor of surgery at the Palo Alto VA is high-risk gastrointestinal cancer surgeries — like taking out a 25-pound liver tumor or removing a tumor from the pancreas with the notoriously difficult Whipple procedure. That’s what she lives to do. Like most surgeons, she has always been commander-in-chief in the operating room. It is her stage. She jokes. She picks the music. She hums along. She gives the orders and then taps her fingers with irritation on the sides of the operating table until they are followed. The OR is her universe, her world. Self-confidence is key in this life-or-death arena, where slipshod work is not an option. Once a body is sliced open, time is precious. Speed is essential. The sooner the patient gets sewn back up, the better. Surgery is always a risk. Minimizing that risk and achieving results is her job.
It’s more than her job, of course. It’s her calling.
“The first time I saw surgery, I thought, ‘Oh my God! That’s what I want to do. You get to fix it!’” says Wren.
It wasn’t her lifelong dream to become a surgeon. Wren was just a good student who grew up in Chicago, where her father had a TV repair and car radio installation shop, and her mom stayed at home to raise Wren and her three brothers. She was the first and only person in her family to graduate from college, studying biology at Carleton College, in Minnesota, then attending medical school at Loyola University in Chicago. That was where she first saw surgery and fell in love. Once she became a surgeon, “I’ve always defined myself first as a surgeon,” she says.
Wren is married with no children. Her two bull terrier dogs have personalities to match her own — stubborn, independent, lovable. Almost equal to her passion for surgery is that for deep-sea diving that has taken her to the wilds of New Guinea, where she danced in the rain with the natives, ate foot-long tree worms and survived a cyclone at sea.
“Sherry will try anything,” says her friend and diving partner Lynne Maxwell, MD, an anesthesiologist from Philadelphia who saw firsthand the eating of the worm and was with her during the Malaysian shipwreck.
That same fearlessness is present in the OR.
Wren likes the challenge of performing high-risk surgery. She takes on the “peek and shriek” cases: “Another surgeon will open up a patient and say, ‘Ohmigod, it’s too this or too that,’ and close him back up,” Wren says. Not Wren.
“She’s just a powerhouse,” her friend and fellow surgeon Myriam Curet, MD, says. “She takes care of very sick patients with very difficult problems. Everybody trusts her.”
The scuba diving gives her a release from this stressful world of high-risk surgery, she says, although others say that she’s just an adrenaline junkie — a stereotypical surgeon.
“I do operations where I really can kill somebody,” she says. “I’m always worrying about whether the patient will be OK. It’s critical to unwind. Diving is the only time I can shut that out.” Which she does on a boat out in the middle of nowhere with no cell reception, no Internet service. Just the deep blue sea and swimming with the fish four to six hours a day.
In her spare time, Wren volunteers for Doctors Without Borders, performing medical missions to Chad, the Congo, Ivory Coast. She has saved many lives with the power and skill of her hands — popping dislocated hip joints back into place, relieving brain bleeds with a hand drill, doing C-sections.
“You have no idea how physically hard it is to crank a 6-millimeter pin into someone’s femur with a hand drill,” Wren says. “And I’m strong.
“I could survive with my legs paralyzed, but not my hands.”
She takes enormous pride in her powerful hands. They are blessed hands, no question. So when, suddenly, those hands lost their strength, when the left hand began to shrivel before her eyes and started to look skeletal, it shook her to the core.
These aren’t my hands. They’re an alien’s hands, she thinks. They don’t belong to me.
They are small, feminine hands. The fingers are slender. The white, unmanicured nails are visible through clear, surgical gloves. Her voice is loud. Her personality fills the enclosed, white-walled operating room. Her hair is naturally curly and red. She’s a bit like a small tank, one that can bulldoze its way through walls. Not much can stop her.
It’s 9:30 a.m. The abdomen incision is made. Six scrubs-wearing, plastic-gloved medical professionals surround an operating table at the Palo Alto VA hospital. The workday begins.
Wren’s hands slip nicely into the open, bloody abdomen. They work in sync with each other, and gently push around the internal organs, the small and large intestine, folding back the peritoneum — the lining of the abdominal cavity — searching and uncovering the vena cava, the gallbladder and the pancreas. She reads the internal anatomy of her patient like a well-known neighborhood map. Her students, the young doctors and surgeons gathered around the patient’s chest, watch her hands closely. They study those hands. The hands teach them their anatomy lessons so that someday they too can save lives. So that they too someday can perform the Whipple, the crown jewel of surgeries.
“That’s why I keep telling you you’ve got to know your anatomy,” Wren says, as she constantly quizzes them on the names of organs and veins.
Like a ballplayer, it’s said that she has “good hands,” that she has amazing hand-eye coordination.
“Don’t dig into the liver,” she warns the chief resident as she guides his hands through the labyrinth of intestinal organs. The liver, a large, dark mass, rests a bit ominously just above the intestines.
“I can feel his pulse behind his bile duct, which makes me...,” her voice trails off. The room tenses. “That makes me want to get down to business.”
The minutes tick past as the surgeon and chief resident cut and sew, cut and sew. Back and forth they pass the scissors and the needles and the suctioning instruments.
The wall clock moves past 10:30 a.m., past 11:30 a.m.
Her left hand works as hard as the right. It’s the support hand. The stalwart, dependable, indispensible force. The left hand digs down deep into the guts.
“All right, let’s get this gallbladder out,” she says. The surgery had really only just begun.
For about a month after her surgery, Wren had to use a walker. She needed help to wash her hair. She couldn’t drive. She was forced into dependency, and she hated it. She started seeing a psychiatrist to help adjust. Still, the day after she returned home from neck surgery, she was back at work. Friends told her to go back home to finish recovery, but she returned again the next day. She could still perform many of her duties, treating patients at the clinic and continuing her teaching rounds.
But the doors to the OR were closed.
“It’s not easy to slow her down,” says her friend Kim Rhoads, MD an assistant professor of surgery at Stanford. “It takes a lightning strike from the universe, something like a shipwreck. Seriously, it took that whole ship sinking.”
Nerve recovery can continue for up to two years after damage. But it happens slowly, nerves growing about 1 millimeter per day. Without the nerve innervation the muscles will atrophy. Exactly how much the damaged nerve will grow back in Wren’s case remains an unknown. Some of her motor functions came back quickly. Soon enough, she could walk, drive a car and wash her own hair. The right hand regained much of its strength as well. But the left hand, the one frozen in the shape of a claw immediately after surgery, remained a problem.
In the first few months after surgery, Wren’s No. 1 motivation was not just getting back to operating, but to return to those marathon surgeries. The ones that last eight, 10, 14 hours. Even though she’s right-handed, she needs a strong left hand as well to do those surgeries. She wanted the Whipple back.
“My left hand is the control hand that sets everything up,” she says. “There are no one-handed surgeons.”
But as the months passed, her left hand began to atrophy. At some point during those months of rehabilitation — even though she knew objectively that it made no sense — her hands started to look foreign to her. My hands are stronger than these. These are someone else’s hands.
“It was so depressing,” Wren says. “My entire life I’ve always had really good hand-eye skills. I was really strong for a woman. I regained my dexterity quickly after surgery, but the nerves were not innervating my muscles. My muscle strength would die in like a second.”
For the next six months, she did six to eight hours of occupational and physical therapy each week. Her competitive nature kicked in, and she tended to overdo it. Her home filled with rehab equipment — weights, exercise bands, exercise balls. She pushed hard. Sometimes she met Rhoads for lunch on Fridays and talked about her goals. What would she do if she didn’t get enough hand strength back to be able to do the
“We’d talk about, ‘Do you have to keep doing Whipples?’” Rhoads says. “There’s a kind of pecking order of operations, according to their risk. The Whipple is the Cadillac of operations and attests to a surgeon’s technical skills. It’s the tippity-top of the pecking order of operations. It’s very high-risk surgery.
“She was trying to figure out who would she be without this part of herself. I think that’s when she started teaching others her global health skills, holding classes for other surgeons, developing a reputation as an expert in another area.”
After six months of hand rehab, Wren finally walked through the operating room doors once again dressed in scrubs. She started with the short, 45-minute, easy-to-do surgeries — the hernias, the gallbladders. Her technical skills were still good, she could see that. The surgeries went well. But still, there was something wrong.
“I went back in very slowly. Everyone said, ‘You’re doing fine.’ But I made my partners watch me to make sure I was doing everything right. I would go into the scrub sink and look at my hands and think, ‘These are not my hands.’
“For the first time in my life, I felt I’d lost all confidence. I felt horrible. I could see objectively that I was operating fine. But I couldn’t get it out of my mind that I was doing something dangerous.” The depression descended over her like a blanket, blinding her. She didn’t want to get out of bed in the morning. “Like many people, I saw it as a personal weakness that I could not dig myself out of. I was in such a dark place. I thought, ‘My hand is horrible. I’m a horrible person.’”
On a sunny Sunday morning in the winter of 2012, Wren sat in the backyard of her friend Curet, the fellow surgeon and consulting Stanford professor. While they watched Curet’s 6-year-old twins jump on a trampoline, Wren opened up about the depression.
“I remember being really surprised how deeply this had affected her,” Curet says. “What all of us saw at work was that she was back to doing cases. She had this external confidence. Everything looked fine.
“She seemed too depressed to be able to focus. I told her about my own experience with this. I told her it seemed to me like her depression might do well with medication, maybe antidepressants.”
Within a week and a half after taking an antidepressant, Wren says she began to feel better. She took the medication for six months, saw the psychiatrist for a year. Today, her left hand is still weaker than it was, but that’s OK. The depression is gone.
“It makes no sense to me why the medication worked, but within a week and a half, I began to feel better,” Wren says. “It allowed me to have confidence again. I stopped looking at my hands as if they were an alien’s. Myriam telling me about her own experience made me feel it was OK to get help. It’s a good thing to have friends.”
Still at it
The goal of the pancreatoduodenectomy, the Whipple procedure, is to remove the head of the pancreas, where most tumors occur. Because the pancreas is so integrated with other organs, the surgeon must also remove the first part of the small intestine (duodenum), the gallbladder, the end of the common bile duct and sometimes a portion of the stomach. The Whipple procedure is a difficult and demanding operation for both the person undergoing surgery and the surgeon. — Mayoclinic.org online definition
At 11:30 a.m., two hours into surgery, Wren’s hands are in constant motion inside her patient’s abdomen, cutting, suturing, mopping up blood with pads of gauze.
“We’re going to start seeing the vena cava soon,” she tells her excited students.
She’s singing along softly with the Grateful Dead song playing from her iPhone.
“Truckin’, got my chips cashed in. Keep truckin’, like the do-dah man. Together, more or less in line, just keep truckin’ on....”
Her hands continue their tour inside the patient’s body, until they find what they are searching for: the pancreas, hidden deep inside the abdomen.
“Damn it, I love it when anatomy works,” she says. She holds the still-attached pancreas gently in both gloved hands, passing it around for the outstretched fingers to feel the life-threatening tumor embedded there.
“It’s a gigantic rockasaurus,” she says.
“Oh my gosh!” says one of the residents.
“Now will be the decision-making time,” Wren says. “Now we are going to decide whether we do this bad boy.” The tumor has grown around a vein, making it both difficult and dangerous to remove. The four hours of surgery up to this point have all been prep work to determine if the tumor is operable. Now it’s time to decide whether they will be able to save the patient’s life. Wren, of course, makes the decision.
It’s a go.
The hands on the clock move from 1 p.m. to 2 p.m. to 3 p.m. The surgeons cut and sew. Cut and sew. One of the tiny cut veins suddenly spurts blood across the surgeons’ faces.
“Jesus!” Wren says, looking around at her students. “You can’t flinch. You’ve got to learn how to sew while your face gets splashed.”
As the hours pass, Wren’s left hand continues to work. It holds back the intestines with a pair of large, metal forceps while the chief resident cuts and sews. And holds. And holds. Five minutes stretch into 10, stretch into 15. Finally, the chief resident ties off the suture and Wren’s left hand can relax.
She grimaces and shakes out the cramping hand.
“Is it still bothering you?” someone says.
“Still not enough nerve innervation,” she says. Then shrugging, she gets back to work.
“Now let’s get this tumor out.”
During this eight-hour-long Whipple surgery in March 2014, Wren’s left hand cramps only once. The tumor is successfully removed. Now she’s left to worry about her patient’s recovery.
A new life
The Whipple is back to being a routine procedure for Wren. Six months after waking up partially paralyzed in June 2012, she was back at it. The following month, she bought all new dive equipment to replace what she had lost at the bottom of the South China Sea. She wasn’t yet strong enough to put it on herself, but seven months after that — August 2013 — she was back deep-sea diving with Maxwell and swimming with the whale sharks of Indonesia.
“Everyone thought I was crazy,” Wren says. Her first question when she boarded the diving boat was, “Does the captain speak English?”
Life is different for her today, two years after her paralysis. She’s lost some extension and flexion in her neck. Her left hand isn’t as strong as it once was. But she can tip her head back in the shower to wash her own hair. For that, and so much more, she is grateful.
“I learned some important lessons,” she says. “One is that confidence is not something you can pick up off of a store shelf.” In the past, she had told many of her students that they just needed more confidence to be good surgeons. At the time, she had no idea how difficult it could be to get that confidence. She had never experienced what it was like not to have it.
“As a teacher of surgery, I will never tell another student that you just need more confidence.”
The journey to return to surgery has made her both a better physician and a better teacher, she says. She understands better what her patients want. She knows better what her students need.
She thought long and hard before deciding to tell her story to others but ultimately decided that maybe someone else could learn from her experience, says Wren, always the teacher.
“This was a real life test for me,” she says. “I truly understand now, there always can be unexpected complications.”
Two years ago, surgeon Sherry Wren had surgery herself. It was a procedure to remove a ruptured disc, and it resulted in a partial paralysis that temporarily derailed her career.
In our interview she shares her pain — both physical and mental — and how the journey to return to surgery made her both a better physician and a better teacher.