This weekend, I participated in a group doing surgical procedures on a healthy anesthetized pig to learn techniques and how to use hemostatic materials; some people have a very strong feeling that doing practice surgeries on animals is unethical and cruel, but others feel it is essential to training and improved outcomes for our human patients. I’d like to discuss some of the issues and also my experiences.
Dressed for surgery in scrubs, capped and gowned, with sterile gloves held above my waist and in front, I look down at the small window of pink back poking through the field of blue sterile drapes. I exhale deeply, a little bit of fog forming on the bottom part of my glasses. I had forgotten to secure the top of my surgical mask with tape. I place my gloved hand on the piece of exposed back. It’s warm, and the pink skin, with its little bit of hair on this juvenile pig, seeming very human-like. I can feel the respirations and heart beat of the intubated and sedated creature. It is very much alive, its warmth surprising (I look it up later and see that the normal temperature of a pig is 101-103 degrees Fahrenheit). The pig is intubated, with several IV lines in place. If I look at the face, it looks like it is sleeping peacefully.
We feel out the spine and mark out a plan for our surgical incision with a pen. Holding the scalpel in my hand (trying to minimize any shaking), I press it down, not enough force at first, using too much of the point of the blade and not enough of the belly, I make the first incision. We are here to practice using some new tools for controlling bleeding intra-operatively. It’s more for the residents than for me, but they let me do most of the actual opening and surgical procedure, and they then practice using the different hemostatic materials. Because it is all about bleeding, having a living subject is essential. I have done procedures on cadavers from wonderful individual who have donated their bodies to science and medicine, and certainly worked through a human cadaver as part of my anatomy training, but working on a living, breathing, bleeding, being with a pulsing heart is a completely difference experience.
I’ve also worked on surgical simulators. They have some great computerized tools, with haptic interfaces which let you practice things like laparoscopic gallbladder and appendix removal. I have also practiced gallbladder removal from a cow liver with the gallbladder still attached, obtained from a local butcher. The liver was placed in a special box, and we used all the same surgical tools used in laparoscopic tools used in real surgery, so much of the technique and maneuvers is the same. However, the experience of working with a living creature is important, it’s extremely different. In real surgeries, control of bleeding is a key part of the process. It is very difficult to simulate all the intricacies of this process. You need a real, living creature to learn how to do this, at least for now. There are also many other subtleties, including how the tissue looks, feels and responds. If you want to follow the healing/recovery process later, then you will need to watch a living creature after time. If you want to be doing normal type surgical procedures you need to be working with an animals of approximately the right size (not rats). There are also many little intricacies that you only get to learn from a “dress rehearsal” of surgery. For example, I was wearing Dansko clogs instead of my usual footwear, thinly soled sneakers. Danskos are very popular, so I thought I would give them a try. However, for these particular procedures, where you need fine control of the foot pedals controlling the drill used to open the “burr holes” in the skull, they were extremely awkward, and I felt like I had very poor control. It minor thing, but just one element of the entire process where you want every move to be the most precise you can make.
The training of surgeons involves learning a very difficult craft. You need to practice a lot, and one of the major ways to learn is to make as many mistakes as early as possible.
“An expert is a person who has found out by his own painful experience all the mistakes that one can make in a very narrow field.” – Niels Bohr
Where do you want those mistakes to be made? Every trainee needs to have a first time and a second time to do something, even if they have watched dozens of that task. Should the first time always be on a person, or is it good to have some of those first times on a model animal (a type of animal often used for food). It might be easy to say that you’d rather have a junior surgeon practice a given procedure dozens of times on a pig or other animal before touching you with a knife.
However, this is a living creature, in the case of a pig, quite a smart creature. What we are doing is an invasive procedure. We are not benefiting the life of the pig at all. Likely, the pig would live a bit longer and then be used to make bacon. Actually, the anesthetics used to end the pig’s life would likely be slightly more humane than the procedures used in a slaughterhouse. However, in either case the pig’s life is being sacrificed to serve the wants of humans. In this case, the pig is going to be “sacrificed” after our procedures and presumably incinerated. Would it be more ethical if we used drugs/materials/procedures in such a way that it could be used for food afterwards? That may sound disgusting, but at the same time many people find “using the whole animal” to be a more ethical approach to sacrificing the life of an animal for food or materials (e.g. leather).
During the spinal procedure (laminectomy), I discovered that the electrocautery near the spinal roots can cause the lower legs to twitch. That was a surprise. Apparently, there are rules (laws?) about not using paralytics on animals used for these surgical sessions. After this procedure we moved to the head and started a craniotomy. Proceeding through several careful steps with different devices, we opened the skull (living bone, full of blood vessels, alive and bleeding). Beneath the skull, we came to the leathery covering of the brain, the dura mater. After extremely carefully opening the material, we came to the pulsing, living brain. It was quite an awe inspiring sight. However, what was perhaps even more enjoyable was the closing part of the process. Carefully putting tiny sutures into the dura, drawing the edges together, I felt like I was accomplishing something good. Some part of my desire to make things clean and orderly, a desire to fix things was be satisfied. As the resident carefully applied the bone cement and sculpted the material as it hardened, it looked “good as new”, and it was incredibly satisfying.
During the whole process, I learned an incredible amount about the tools and techniques of surgery. Was it an ethical thing to do? I don’t know. I think so. I think it helps me understand a lot more about the practice of surgery. I don’t think anything done was particularly cruel or caused pain, as the animal was anesthetized the whole time and then given a lethal injection, expiring calmly in its sleep. Overall, I think I would gladly have an animal die to help me better doctor than to have one die so someone can have a more artery clogging breakfast. Others may not agree. Approximately 5-13% of Americans are vegetarians. I don’t know for any individual if that is for health or ethical reasons. They may think that ending the life of an animal for educational or research purposes. I don’t know what the right answer is. I’m just trying to do my best and learn how to be a good doctor. Trying to learn how to not make any mistakes with patients. Trying to do the best I can with all my patients, however briefly they are in my care, human or animal.