by Jodi Picoult
Late at night on the patient floors, Nicholas learned to listen. He could tell by the flat beat of soles on the tiles when the nurses were making the midnight rounds. He saw old men recovering from surgery meet in the patient kitchens at 3:00 a.m. to steal the red jello. He waited for the slosh and whistle of the heavy industrial rag mops, shuffled up and down the halls by half-blind old Hispanic janitors. He noticed every patient call sounded at the nurses' desk, the tear of sterile paper that revealed virgin gauze, the sucked-in breath of a syringe. When he was on call and things were quiet, Nicholas liked to wander around the floors, his hands deep in the pockets of his white lab coat. He did not stop into patient rooms, not even when he was on a general surgery rotation and the patients were more than just names and charts posted on the door. Instead he moved like an insomniac, roaming, interrupting the night with his own shrouded footsteps.
Nicholas did not wake Serena LeBeauf when he entered her room in the AIDS ward. It was well after two in the morning by the time he could spare a minute. He sat down in the stark black plastic chair beside her bed, amazed by her deterioration. Her vitals indicated that she weighed less than seventy pounds now; that she had pancreatitis, respiratory failure. An oxygen mask covered her face, and morphine dripped into her continuously.
Nicholas had done something very wrong the first time he met Serena--he let her get under his skin. It was something he had hardened himself to, seeing death every day the way he did. But Serena had a wide smile, with shocking white teeth; eyes light like a tiger's. She had come in with her three children, three boys, all of different fathers. The youngest, Joshua, was six back then, a skinny kid-- Nicholas could see the bumps of his backbone under his thin green T-shirt. Serena did not tell them she had AIDS; she wanted to spare them the stigma. Nicholas remembered sitting in the consultation room with the attending physician when she learned she was HIV positive. She had straightened her spine and had gripped the chair so tight that her fingers whitened. "Well," she had said, her voice soft like a child's. "That's not what I expected." She did not cry, and she asked her doctor for all the information she could get, and then, almost shyly, she asked him not to mention this to her boys. She told them, and her neighbors and distant relatives, that it was leukemia.
Serena stirred, and Nicholas pulled the chair closer. He reached for her wrist, telling himself it was to check her pulse, but he knew it was just to hold her hand. Her skin was dry and hot. He waited for her to open her eyes or to say something, but in the end he held his palm soft against her cheek, wishing he could take away the gray haze of her pain.
Nicholas began believing in miracles his fourth year of medical school. He had been married just months when he decided to do a rotation in Winslow, Arizona, for the Indian Health Service. It was only four weeks, he'd said to Paige. He was tired of doing the scut work of interns at Boston-based hospitals: patient histories and physical exams, clerking for residents and attendings and anyone ranked above you. He'd heard about the rotation on the reservation. They were so short-staffed that you did everything. Everything.
It was a three-hour drive from Phoenix. There was no town of Winslow. Black houses, abandoned shops and apartments, stood impassively around Nicholas, their empty windows blinking back at him like the eyes of the blind. As he waited for his ride, tumbleweed edged across the road, just like in the movies, skittering over his shoes.
Fine dust covered everything. The clinic was just a concrete building set into a cloud of earth. He'd taken a red-eye flight, and the doctor who'd met him in Winslow had been there by 6:00 a.m. The clinic wasn't open yet, not officially, but there were several parked pickup trucks, waiting in the cold, their exhaust hanging in the air like the breath of dragons.
The Navajo were quiet people, stoic and reserved. Even in December, the children had played outside. Nicholas remembered that --the brown-skinned babies in short sleeves, making snow angels in the frosted sand, and nobody bothering to dress them more warmly. He remembered the heavy silver jewelry of the women: headbands and belt buckles, brooches that glittered against purple and deep-turquoise calico dresses. Nicholas also could remember the things that had shocked him when he first arrived: the endless alcoholism; the toddler who bit her lip, determined not to cry as Nicholas probed a painful skin infection; the thirteen-year-old girls in the prenatal clinic, their bellies grotesquely swollen, like the neck of a snake that has swallowed an egg.
On Nicholas's first morning at the clinic, he was called into the emergency room. A severely diabetic elderly man had consulted a shaman, a tribal medicine man, who had poured hot tar on his legs as part of the treatment. Horrible sores blistered up, and two physicians were trying to hold down his legs while a third examined the extent of the damage. Nicholas had hung back, not certain what he was needed to do, and then the second patient was brought in. Another diabetic, a sixty-year-old woman with heart disease, who had gone into cardiopulmonary arrest. One of the staff doctors had been jamming a plastic tube down the woman's throat to manage the airway and to breathe for her. He did not look up as he shouted at Nicholas. "What the hell are you waiting for?" he said, and Nicholas stepped up to the patient and began CPR. Together they had tried to get the heart moving again, forty minutes of CPR, defibrillation, and drugs, but in the end the woman died.
During the month that Nicholas spent in Winslow, he had more autonomy than he'd ever had as a student at Harvard. He was given his own patients. He wrote up his own notes and plans and ran them by the eight staff physicians. He rode with public health nurses in four-wheel-drive vehicles to find those Navajos with no true addresses, who lived off the paths of roads, in huts with doors that faced the east. "I live eight miles west of Black Rock," they wrote on their face sheets, "just down the hill from the red tree whose trunk is cleaved in two."
At night Nicholas would write to Paige. He mentioned the dirty hands and feet of the toddlers, the cramped huts of the reservation, the glowing eyes of an elder who knew he was going to die. More often than not, the letters came out sounding like a list of his heroic medical feats, and when this happened Nicholas burned them. He kept seeing the unwritten line that ran through the back of his mind: Thank God this isn't the kind of doctor that I'm going to be--words never committed to paper that were still, he knew, indelible.
On his last day at the Indian Health Service, a young woman was brought in, writhing in the throes of labor. Her baby was breech. Nicholas had tried palpating the uterus, but it was clear a C-section was going to be necessary. He mentioned this to the Navajo nurse who was acting as translator, and the woman in labor shook her head, her hair spilling over the table like a sea. A Hand Trembler was called in, and Nicholas respectfully stepped back. The medicine woman put her hands over the swollen belly, singing incantations in the language of the People, massaging and circling the knotted womb. Nicholas told the story when he returned to Boston the next day, still thinking of the dark gnarled hands of the medicine woman, suspended above his patient, the red earth flurrying outside and hazing the window. "You can laugh," he said to his fellow interns, "but that baby was born headfirst."
"Nicholas," Paige said, her voice thick with sleep. "Hi."
Nicholas curled the metal cord of the pay phone around his wrist. He should not have awakened Paige, but he hadn't spoken to her all day. Sometimes he did this, called at three or four in the morning. He knew she'd be asleep, and he could imagine her there with her hair sticking up funny on the side she'd been sleeping on, her nightgown tangled around her waist. He liked to picture the soft down comforter, sunken in spots where her body had been before she had reached to answer the phone. He liked to imagine that he was sleeping next to her, his arms crossed under her breasts and his face pressed into her neck, but this was unrealistic. They slept at opposite sides of the bed, both fitful sleepers, unwilling to be tied by someone else's movements or smothered by someone else's heated skin.
"Sorry I didn't call this afternoon," Nicholas said. "I was busy in ICU." He did not tell P
aige about the patient he'd had to code. She always wanted details, playing him for a superstar, and he wasn't in the mood to go into it all over again.
"That's okay," Paige said, and then she said something muffled into the pillow.
Nicholas did not ask her to repeat herself. "Mmm," he said. "Well, I guess I don't have anything else to say." When Paige did not respond, he hit the # button on the phone.
"Oh," Paige said. "Okay."
Nicholas scanned the hall for signs of activity. A nurse stood at the far end, dropping little red pills into cups that were lined up on a table. "I'll see you tomorrow," Nicholas said.
Paige rolled onto her back; Nicholas knew by the crinkling of the pillows and the fluff of her hair when it settled. "I love you," Paige said.
Nicholas watched the nurse, counting the pills. Eighteen, nineteen, twenty. The nurse stopped, pressed her hands into the small of her back as if she was suddenly weary. "Yes," Nicholas said.
The next morning Nicholas did prerounds at five-thirty and then began regular rounds with Fogerty and an intern. The patient Nicholas had coded yesterday was doing fine, comfortably settled in surgical ICU. By seven-thirty they were ready for their first surgery of the day, a simple bypass. As they scrubbed, Fogerty turned to Nicholas. "You did well with McLean," he said, "considering you'd just come onto the rotation minutes before."
Nicholas shrugged. "I did what anyone would have done," he said. He scrubbed at invisible germs under his nails, around his wrists.
Fogerty nodded to an OR nurse and shrugged into his sterile gown. "You make decisions well, Dr. Prescott. I'd like you to act as chief surgeon today."
Nicholas looked up but did not let the surprise he felt show in his eyes. Fogerty knew he'd been on call all night, knew he'd need a second wind to measure up. Fogerty also knew it was virtually unheard of for a third-year resident to lead a bypass operation. Nicholas nodded. "You got it," he said.
Nicholas spoke quietly to the patient as the anesthesiologist put him under. He stood beside Fogerty as the second assistant, a resident more senior than Nicholas who was obviously angry, shaved the legs, the groin, the belly, and covered the body with Betadine solution. The patient lay motionless, stark naked, stained orange, like a sacrifice for a pagan god.
Nicholas supervised the harvest of the leg vein, watching as blood vessels were clamped off and sewn, or were cauterized, filling the operating suite with the smell of burning human tissue. He waited until the vein was settled in solution for its later use. Then, stepping up to the patient, Nicholas took a deep breath. "Scalpel," he said, waiting for the nurse to pick the instrument off a tray. He made a clean incision in the patient's chest and then took the saw to cut through the sternum. He held the ribs spread apart with a rib spreader, and then he exhaled slowly, watching the heart beating inside the man's chest.
It never failed to amaze Nicholas how much power was in the human heart. It was phenomenal to watch, the dark-red muscle pumping quickly, turning hard and small with each contraction. Nicholas cut the pericardium and separated out the aorta and the vena cava, connected them to the bypass machine, which would oxygenate the blood for the patient once his heart was stopped by Nicholas.
The first assistant poured the cardioplegia liquid onto the heart, which stopped its beating, and Nicholas, along with everyone else in the room, turned his eyes to the bypass machine, to make sure it was doing its job. He bent closer toward the heart, snipping at the two coronary arteries that were blocked. Nicholas retrieved the leg vein, delicate, and turned it so that the valves did not hold blood back but let it through. With careful sutures he sewed the vein onto the first coronary artery before the point of blockage, and then attached the other end after the point of blockage. His hands moved with a will of their own, precise and steady, fingers blunt and strong beneath the translucent gloves. The next steps streamed through his mind, but the procedure and his role in it had become so natural to him, like breathing or batting right-handed, that Nicholas began to smile. I can do this, he thought. I can really do this on my own.
Nicholas finished the bypass five hours and ten minutes after he'd begun. He let the first assistant close for him, and it was only after he'd left the operating suite to scrub that he remembered Fogerty and the fact that he hadn't slept in twenty-four hours. "What did you think?" Nicholas said to Fogerty, who was coming up beside him.
Fogerty peeled off his own gloves and ran his hands under the hot water. "I think," he said, "you should go home and get some sleep now."
Nicholas had been untying his mask, and in his shock he let it drop to the floor. He had just done his first bypass, for God's sake. Even an asshole like Fogerty should have some constructive criticism, maybe a word of praise. He'd done a terrific job, not one glitch, and even if it took an hour longer than Fogerty's usually did, well, it was to be expected because it was his first.
"Nicholas," Fogerty said, "I'll see you at evening rounds."
There were many things about Paige that Nicholas did not know when they had been married. He celebrated her birthday two weeks late because she had never told him when it was. He couldn't have guessed her favorite color until their first anniversary, when she picked emerald stud earrings over sapphires because of their sea-green glow. He certainly couldn't have predicted her disastrous cooking experiments, like Miracle Whip Stew and Turkey-Marshmallow Kabobs. He didn't know she'd sing car-commercial jingles when she dusted or that she'd have the skill of stretching a paycheck to cover the interest on a graduate student loan, groceries, condoms, and two tickets to the discount movie theater.
In Nicholas's defense, he did not have much time to discover his new wife. His rotations kept him at the hospital more often than he was at home, and after he graduated from Harvard, he was even more pressured for time. When he did stumble into the apartment, starved and blind with fatigue, Paige so seamlessly fed him, disrobed him, and loved him to sleep that he began to expect the treatment and sometimes forgot that Paige was connected to it.
When he came home from performing his first solo bypass, he did not turn the lights on in the apartment. Paige was at work. She was still waiting tables at Mercy, but only in the mornings. Afternoons, she worked at an ob/gyn office as a receptionist. She had taken on the second job after some night courses in architecture and literature at Harvard Extension didn't work out. She hadn't been able to keep up with the reading and the housework and told Nicholas that two incomes meant more money and that more money meant they'd move out of debt more quickly so she could go to college full time. Back then, Nicholas had wondered if it was just an excuse to drop out of her classes. He'd seen her attempts at writing papers, after all, which were really no more than high-school caliber; and he'd almost said something to Paige, until he remembered that it was just what they would be.
Nicholas never voiced his doubts to Paige. For one thing, he didn't want her to take it the wrong way. And also, Nicholas had hated seeing her surrounded by yellowed used textbooks, her hair springing free of its braid as she wound her fingers through it in concentration. Truthfully, Nicholas liked having Paige all to himself.
She was at the gynecologists' office, since it was well after two, but she'd left him a meal to heat up in the oven. He didn't eat it, although he was very hungry. He wanted Paige to be there, although he knew it wasn't possible. He wanted to close his eyes and, for once, become the patient, soothed by the cool ministrations of her tiny, fine hands.
Nicholas fell onto the bed, neatly made, amazed by the darkness and the cold of the late day. He fell asleep listening to the beat of his own heart, thinking of the directions patients gave at the Indian reservation. My home is west of Mass General, he would say, light-years beneath the brittle winter sun.
Serena LeBeauf was dying. Her sons were heaped like huge puppies on the edges of the hospital bed, holding her hand, her arm, her ankle--whatever pieces of her they could hold. They had brought things they thought would comfort her. There on her frail chest was the cut-out travel-
brochure picture of San Francisco, where she'd lived when she was younger. Tucked under her arm were the stubby remains of a threadbare stuffed monkey. Curled across the hollow of her belly was her diploma, the college degree she'd worked so damned hard for and received just a week before her AIDS was diagnosed. Nicholas stood in the doorway, not wanting to intrude. He watched the liquid brown eyes of Serena's sons as they stared at their mother, and he wondered where they would all go, especially the little one, when she died.
He was paged, and he raced down three flights of stairs to surgical ICU, where his bypass patient was lying. The room was a rush of activity, physicians and nurses jockeying into place as the heart went into failure. As if he were watching a replay of the day before, Nicholas stripped the gown from his patient and gave an external shock. And another. Sweat ran down his back and into his eyes, searing. "Goddammit," he muttered.
Fogerty was there. Within minutes he had moved the patient to an operating suite. Fogerty cracked the chest open again and slid his hands into the bloody cavity, massaging the heart. "Let's go," he said softly. His gloved fingers slipped over the tissue, the still-new sutures, rubbing and warming the muscle, kneading life. The heart did not pulse, did not beat. Blood welled around Fogerty's fingers. "Take over," he said.
Nicholas slipped his own hand around the muscle, forgetting for a second that there was a patient, that there was a past attached to this heart. All that mattered was getting the thing going again. He caressed the tissue, willing it to start. He pumped oxygen through his patient's system manually for forty-five minutes, until Fogerty told him to stop and signed the death certificate.
Minutes before Nicholas left the hospital for the night, Fogerty called him to his office. He was sitting behind the mahogany desk, his face shadowed by the slatted vertical blinds. He did not motion for Nicholas to enter, did not even lift his head from the paper he was writing upon. "You couldn't have done a thing," he said.