Inhaling the field – surgery, smoke, and smells

Renée van der Wiel //

Up until that morning I had spent most of my fieldwork in stuffy, linoleum-lined hospital reception areas accompanying women on their clinical treks. We would chat while waiting to hear a “NEXT!”  But before concluding my ethnography of a public breast cancer clinic in Johannesburg, I arranged to spend a day in the operating theatres. I would finally enter the natural habitat of the surgeons I had gotten to know.

Body-conscious and thankfully alone in the women’s changing area, I put on a pair of hospital-branded scrubs. They were a washed out turquoise-grey, as was the elasticated showercap-esque hair covering I had been given. Just donning the exotic garb felt exhilarating. I took a quick, out-of-focus selfie and entered the theatre complex. 

The social life of the operating room was interesting. Not surprising, seeing as I was there as a postgraduate social anthropologist. I had not seen interaction and medical work like that before. Up until that point, I had mostly accompanied patients from one practitioner to another – counsellors, radiologists, surgeons, and wound-care nurses. In theatre, I was surprised by the teamwork, the focused attention on the patient, and the clear roles that everyone undertook and seemed, at least from my short visit there, to enjoy. This was in sharp contrast to other parts of the hospital where many health professionals came across as exasperated, if not tetchy or even a touch terrifying. However, alongside these social dynamics the corporeality of the operating rooms was the real and sensory surprise.

As a self-conscious observer trying not to get in anyone’s way, I initially tried to stay in the background, sticking nervously to the walls, although I soon realised that, being in a teaching hospital, it was acceptable and even encouraged for me to be physically involved in the activity of the theatre. One nurse called me in an adjacent storeroom and asked me to help hold open the non-sterile sides of the packaging containing supplies she needed to retrieve. One surgery team cajoled me into holding a large breast tumour that had just been removed from the woman lying unconscious in the centre of the room. I was alarmed by the level of sensation I felt through the surgical gloves including the warm wetness of this “specimen” that a few minutes before had been part of someone. Also surprising was the texture of the margin of soft healthy tissue over the firmer, underlying, golf ball-sized tumour.

Initially while in the theatre, I did not have to wear a surgical face mask as I was nowhere near the patients and hence the surgical field. Eventually, when one of the doctors instructed me to have a closer look at what was happening with the operating table, a nurse hastily passed me a mask. I noticed soon after that an intern had popped into the theatre to check out a procedure being performed on this particular patient whom she had been treating. But the intern did not bother with a mask, she pulled her scrubs top up over her mouth and nose as she leaned in slightly for a quick peek, a nonchalance about mask wearing that seems unimaginable now, in or out of surgery.

I did not feel squeamish, nauseous, or “grossed out” while peering at the patients’ exposed flesh. I noted with curiosity the striking visual difference between fatty tissue and the musculature of the chest wall. The most extraordinary, jarring, slightly sickening experience that day was the overwhelming and foreign stench of the theatre.

Human tissue does not smell good at high temperatures, scorched by a type of electrically-heated scalpel useful for cutting out tumours and for cauterising blood vessels.[1] Whenever this tool was in use I unconsciously held my breath. The windowlessness of these restricted spaces became more apparent. I wanted just the slightest draft of fresh air from the outdoors to dilute the smell of burning flesh. In theatre, people were focused either on the prone patient or on attending to the surgeons’ needs. This, along with me wearing a surgical mask some of the time, meant that luckily the disgust passing over my attempt at a poker face was unnoticed. After all, I did not want to be an impolite or feeble visitor out of her olfactory depth. 

When I later remarked on this intense experience to one of the surgeons, she said that she was obviously so used to the smell she did not really notice it. She was surprised that I had found it overwhelming at times. Several anaesthetists I spoke to years later about this day of fieldwork were also surprised by my observation. I was mystified that anyone could become accustomed to that kind of assault on the senses.

After my day of theatre, I contemplated what was involved in the smoke and smell of surgery. How much of a human being had I inadvertently inhaled? Was that how it worked? How much of an odour is made up of the thing itself? I was following the puerile logic of a child who finds disgust and hilarity in the idea that smelling a fart is the equivalent of inhaling particles of poo. I pondered whether I had inhaled the patients’ singed cells. But was it not part of my mandate as a postgraduate researcher to fully immerse myself in the field? To live, eat, breathe – and smell – the field.

Afterword – voluntary exposure

Going to theatre was an intellectual treat for me. It would be remiss not to consider what and how much theatre nurses, surgeons, anaesthetists, interns, and perhaps even cleaners inhale over the duration of their careers. About four years after my strange day trip, I studied doctors who practiced and did research in other public hospitals around Johannesburg. Some of their research indicated that poorly maintained infrastructure or inadequate resources could in some cases turn healthcare facilities into health hazards. It is not beyond the imagination that ventilation systems and smoke evacuation equipment in theatres such as those I visited do not function adequately. Healthcare workers may inhale a greater volume of their patients’ cauterised cells, or what is known as “surgery smoke,” than may be safe – something that seems to be a matter of scientific debate.[2]

//

This article is written in conjunction with an illustrated essay titled Resuscitation envy: Rubbing up against clinical responsibility https://breath.medicalandhealthhumanities.africa/resuscitation-fascination-rubbing-up-against-clinical-responsibility/ for Breath: Inspire/expire, a symposium convened by Medical and Health Humanities Africa https://breath.medicalandhealthhumanities.africa/


[1] Subsequent to my fieldwork, I read up about these instruments, of which there are evidently a wide variety. Sadly, I did not enquire about the specifics of the tools in use while I was in the operating theatre.

[2] See for example: Kocher, Gregor J. et al. 2018. “Surgical smoke: still an underestimated health hazard in the operating theatre” in European Journal of Cardio-Thoracic Surgery, 55: 4; 626–631. https://doi.org/10.1093/ejcts/ezy356; Casey, Vincent, J. et al. 2020. “Comparison of Surgical Smoke Generated During Electrosurgery with Aerosolized Particulates from Ultrasonic and High-Speed Cuttingin Annals of Biomedical Engineering, Aug 7;1-13. 10.1007/s10439-020-02587-w

Image credit: “Head of a woman with a handkerchief against her nose” (1894) by Julie de Graag (1877-1924). Original from The Rijksmuseum. Retrieved from: https://www.rawpixel.com/image/466910/free-illustration-image-sad-woman-flu

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