MANCHESTER -- The baby girl lies unconscious on the operating table. A tangle of tubes and wires are attached to her tiny body. Her pacifier is still in her mouth.

She needs a tracheostomy tube replaced for the first time after having it implanted in her throat the week before. This first-time replacement is a delicate and dangerous operation. The old tube has to be swapped for a new one very quickly or the airway moves, cutting off oxygen and sending the heart into an irregular rhythm. When this happens, the patient could die within a minute.

Dr. Brian Gilchrist's hands move effortlessly, and less than 20 minutes later, he's telling the little girl's parents that their daughter made it through the surgery just fine.

Outside the operating room, Gilchrist is an energetic, frenetic man with a huge sense of humor who stops his machine-gun chatter only when he's ready to deliver his quick, hearty laugh. That guy goes away when Gilchrist, chief of pediatric surgery at Elliot Hospital, dons scrubs and with sure, gifted hands, becomes the man who fixes broken children.

“Everyone stop! Just stop!” he shouted as some nurses fretted with a malfunctioning machine as he cleaned burn wounds suffered by a 4-year-old girl when hot cooking oil spilled on her head.

In the operating room, Gilchrist is serious and controlled. There is no music playing. No jokes are told. The only talking is about the task at hand.

He is the only board-certified general pediatric surgeon based in southern New Hampshire. This is, he said, both good and bad for parents going through the worst moments of their lives and the children whose lives often hang in the balance.

A rare breed

Calling pediatric surgery “the hardest thing to get into in American medicine,” Gilchrist said the country has a dearth of pediatric surgeons.

There are just 800 board-certified pediatric surgeons in the United States, said Christine D. Shiffer, communications manager for the American Board of Surgery, which certifies pediatric surgeons. Of those, Gilchrist said, just 375 or so are practicing. The others have either retired or have decided to take different career paths in medicine, he said.

That works out to a ratio of one pediatric surgeon for every 197,333 children in the United States.

There are fewer pediatric surgeons in the United States than there are Major League Baseball players.

To become a pediatric surgeon, a medical school graduate must complete five years of general surgery residency, then complete a two-year fellowship specific to pediatric surgery, but only if they are one of the 20 or so accepted into the fellowship each year, Gilchrist said.

“The American Board of Surgery has certainly been the gatekeeper for numbers,” he said. “They have kept the fellowship positions very, very low.”

It's a double-edged sword that, while he understands it, also frustrates him.

“The downside is there is a maldistribution of pediatric surgeons across the country,” he said.

The upside is that when a little girl or boy needs to go under the knife, they're getting the best of the best, he said.

“They want you to have complete and utter expertise in taking care of these kids,” he said.

Including Gilchrist, just three board-certified pediatric surgeons are based in New Hampshire. Two are with the Children's Hospital at Dartmouth, which is part of Dartmouth-Hitchcock Medical Center in Lebanon. However, the surgeons do handle cases at Dartmouth's Ambulatory Surgery Center in Manchester, said Dartmouth-Hitchcock spokesman Rick Adams.

Before Gilchrist was recruited by Elliot Hospital away from the Floating Hospital for Children at Tufts Medical Center in Boston three years ago, no pediatric surgeons were based in southern New Hampshire.

“That's just a terrible situation for a community to deal with,” Gilchrist said.

A drawback to attracting newly minted pediatric surgeons to New Hampshire is trying to persuade them to accept the workload, given the scarcity of surgeons, Gilchrist said.

“These guys want to join groups of eight or 10, so they're only on call every eight or 10 nights,” he said. “You come work for me, you're on call every other night and every other weekend.”

Emotional detachment

An effective surgeon operating on an adult can't have in the back of his mind the speech he'd have to give to the family if an operation goes wrong. Magnify all of that when the patient on the table is a 9-hour-old premature baby, Gilchrist said.

“If you're thinking that, 'God, this kid could die on me and I'd have to go out and tell the mother,' you'd be paralyzed. You wouldn't be able to do it,” he said.

Instead, a surgeon focuses on the task at hand — the appendix that needs to come out or the tumor that needs to be removed. But that doesn't mean Gilchrist doesn't recognize the importance of his job.

“There is no greater sorrow in the world than the loss of a child to a parent,” he said. “It is a grief that is never quenched in a person.”

He also recognizes the pain and fear children have. He often personally escorts children to have X-rays or ultrasound testing performed, rather than leaving the task to an orderly or a nurse.

“It's just a comforting thing to watch him in action,” said Jack Heath, whose daughter, Emma, had an inflamed appendix removed by Gilchrist earlier this year. “I think he really just loves to cure and help kids.”

Though he tries to maintain his all-business exterior in the operating room, sometimes sympathy still makes its way out.

“Oh, this poor kid. Jesus Christ,” Gilchrist said as he continued to clean scabs and caked grease from the 4-year-old burn victim's head.

“My favorite thing is that he loves his patients,” said Gilchrist's physician assistant, Leya Laverriere. “He cares about his patients more than anything else, which is awesome.”

He is a gregarious man who calls several patients “my favorite,” a phrase he admits is used for charm's sake to keep patients comfortable and help alleviate fear.

It would seem disingenuous, if he didn't also know each patient's name and the names of his patients' parents, or didn't ask a 15-year-old appendicitis patient about the upcoming math test she'd told him a few days ago was worrying her.

Do not call him perfect

Gilchrist said he has had two patients die on his operating table. One, who had been impaled in a motorcycle crash, he recognizes was not his fault.

The other, a 16-year-old boy, is different.

Gilchrist was working at Tufts Medical Center in Boston at the time. The boy was in for a routine, minimally invasive surgery called the Nuss procedure, named after Dr. Donald Nuss, who developed it. It involves inserting a metal rod into the chest to correct pectus excavatum, or sunken chest.

It works similar to how braces fix teeth and, like braces, the metal rod is removed after it's done its job and popped the chest out.

“It's a very straightforward, very nice operation,” he said.

Gilchrist removed the rod and, “the anesthesiologist says, 'The kid's gone flatline,'” he said.

“Flatline? We're just closing the skin,” he said, recalling what happened. “I put a chest tube in, and blood comes pouring out.”

What nobody knew — not the boy nor his parents nor Gilchrist — was that the boy had a nickel allergy. The rod, which contained nickel, had fused to the pericardium around the boy's heart. He said for people with a nickel allergy, the metal fuses to tissue similar to how a tongue will stick to a freezing-cold pole.

“As I pulled it out, we ripped a hole in the kid's heart. So the kid died on the table,” he said. “This, I was sort of responsible for, inadvertently.

“It's not something I forget. I think about it almost every day,” he said.

Some good came from the tragedy, he said. At a conference about the Nuss procedure, Gilchrist shared his story about the nickel allergy. Other physicians reported the same complications, and some of them got together to present a paper about the issue.

“So now every kid that gets the Nuss procedure gets tested for a nickel allergy. Every single one,” he said.

Tough Irish boy with a heart

Gilchrist is a third-generation surgeon, the son of Bernard and Breedh Gilchrist.

His dream of playing baseball fizzled out once he got glasses. He said he was convinced that he would pursue a career in politics after seeing what a surgeon's life did to his father.

“He worked so hard,” Gilchrist said. “I played baseball all those years, and he always came to my games late. And he was always stooped and gray.”

Gilchrist ultimately decided to become a doctor, though he said he still has a passion for politics and hasn't ruled out going for political office in the future.

“And when I run, I'm going to win,” he said.

Gilchrist said one of his defining moments as a doctor, and in life, came during an emergency.

While in Boston, he was preparing to operate on an 11-year-old whose spleen had been smashed in an accident when a phone was pressed to his ear and a voice told him: “This is Reverend Pearson in the Tampa Bay General Hospital trauma room. Your brother, Terence, is here, and he's dead.”

He made the priest repeat the words, then demanded to speak to a doctor, from whom he learned that his older brother had been killed by a car while he crossed an intersection. He said his brother, who was gay, was never understood by his strict Irish Catholic parents. Gilchrist wrote about his loss in a Tufts Magazine article.

“I think the pain of losing Terence, and the pain he suffered for 50 years, created in his younger brother a better physician,” he wrote. “You cannot deny the pain of loss, but you can let it wash you onto the shore of empathy, as your pain will clearly show you the pain felt by others.”

After speaking to that Florida doctor, Gilchrist rescrubbed, went back into the operating room and saved that girl's life.

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Tim Buckland may be reached at tbuckland@unionleader.com.