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The surgeon waits to exhale

The headline heralded: Surgery a Success, Summit to Proceed. I could almost hear the air whistling through the teeth of Navy Cmdr. David Adkinson, the surgeon who operated on President Clinton, as he drew a deep breath of dismay, chagrin and apprehension. Surely Dr. Adkinson knows what every surgeon knows: The success of an operation is not told until the patient is well and no longer preoccupied by the incision, the pain, the loss of function, the change in sleep and bowel habits, the disruption of accustomed living that marks the convalescence from all operations.

Mr. Clinton was as cocksure as the headlines, and he took off for Helsinki, Finland, where photographers then captured his image at the summit _ knee brace and all. No problem, he seemed to be saying, just tore my quadriceps tendon and got it fixed.

I imagine Dr. Adkinson thinking: "Sure thing, Mr. President. As long as the sutures hold and the wound doesn't become infected. As long as clot doesn't form in the veins of the immobilized leg. As long as that clot, if it does congeal, doesn't break off from the vein, get swept upstream and lodge in the circulation of the lung, a pulmonary embolism, and kill you; I have seen it happen, so has every surgeon; it is what makes us so wary." But no doubt he keeps his own counsel on these matters, smiles for the cameras (or tries to look earnest and competent), and hopes for the best.

The doctor cannot win, of course. If the president does well, learns to attack his rehabilitation, loses weight, uses this injury to change his cheeseburger life for real and seeks consistent exercise that transforms his physical and then his philosophical existence, Adkinson gets no kudos. After all, he was just doing his job, paid for by the taxpayers of the United States.

But if the wound falls apart, if the tendon does not heal, if the leg is never the same again (and it won't be), Cmdr. Adkinson will be known as the man who let the president down.

So the surgeon wants rest and rehabilitation for his patient, but the handlers want a show of strength and health. The show will go on: See the healthy and commanding president, behold the conduct of state affairs. No surgeon I know would choose an eight-hour plane ride to Helsinki on post-op day four, regardless of the complexity of the procedure or the prominence of the patient. The surgeon grits his teeth and hopes.

Mr. Clinton's injury seems prosaic enough. I'm not sure I believe he was up until 1:20 in the morning without a drink, just talking golf, but that's his story, and it really doesn't matter. What does matter is the lesson about how quickly our lives can be changed by illness. Patients rushed into emergency rooms this afternoon left home this morning without one thought of being hurt or sick. But here they are, gasping for breath or bleeding or holding their knee in pain. Many of them will never be the same. Some will not survive. The surgeon sees this all the time. It affects her thinking daily. She wonders if it will be her lying there.

Most of us don't think like this. We get up, go to work or school, and have very little inkling that something might fell us. We are also unaware of the wonderful machinery whirring away inside us. We pay zero attention to the quadriceps mechanism that allows us to lift our leg and extend our knee. What shortstop thinks of his quadriceps while turning the double play? Suddenly a president stumbles, and experts are sought out, and that night on the evening news we see our famous news anchors staring gravely into the television lens opining about the knee cap. Then they wrestle comically with a plastic model of the knee, trying to show us how a misstep could cause such damage. What else, we wonder, is in there that could be so quickly and profoundly undone?

Oblivious as we are to the elegance of our own internal workings, we are equally unaware of the profound changes in medicine that make such injuries survivable. Hundreds of years ago such a knee injury left a human defenseless, unable to hunt or gather food and, most likely, dead. Today the injury is repaired in a few hours, rehabilitation is started and trips to other continents are carried out. It is only in the past few decades that such repair work has become commonplace.

For the surgeon, operating on prominent people is fraught with trouble. The patient is used to getting his or her own way. No physical ailment will be tolerated. A conservative medical approach is deemed self-serving and self-protective. The pressure to "get with the program" is great, and the weak ones do. The smart ones have learned that the biology of the disease or injury is ignorant of the wealth or station of the patient. Quadriceps injuries heal at the same pace whether you're president or pauper. The smart doctors let their patients know this, even if they don't want to hear it. At some point, Mr. Clinton must take his part of the responsibility for his recovery. What the prominent patient may not know is that he is human.

I don't know Dr. Adkinson, but my bet is that he's still on tenterhooks. Only in the future of the next century, when he turns on the evening news and sees former President Clinton striding across a parade ground with a normal gait, will he know that the surgery was a success. Then he can exhale.

Richard Karl is chief of surgery at the Moffitt Cancer Center and Research Institute at the University of South Florida.