My Own Country

by Abraham Verghese

  “Homosexual?” he asked, pointing at the film. I nodded.

  “It figures,” he said, shaking his head, as if there was some clue to sexuality in the black-and-white image. “Well,” he said, his tone now changing, his face taking on a somber expression as if he was viewing the films of a condemned criminal, “there are no stones there. The gallbladder wall might be just a bit thick. Nothing else I can tell you.” He turned to me. “No telling what can be going on. Sucker could have anything including the kitchen sink, right?”

  I said nothing.

  “It’s just too bad, too bad—”

  I felt a moral statement coming. “I wonder,” I said, “whether he could have acalculous cholecystitis? [An inflamed gallbladder without stones.] There are reports now of this happening in AIDS. Cryptosporidium [a protozoan parasite that causes diarrhea] is thought to produce this, though this will be my first case. We do know he has Cryptosporidium in his bowel causing diarrhea.”

  “Is that right?” The radiologist turned back to the films, his thought train interrupted. He pursed his lips. “Never heard of that bug. Could be, could be. God almighty, what can they expect? Like I said, that wall is a little thickened, maybe some edema there.” He stared a little longer. “But nothing to write home about.” He took the films down and handed them to me. “Pheweee! Well, good luck! Son, I sure wouldn’t want to be in your shoes.”

  I left the elegant radiology suites and took the back stairs up to my patient’s room.

  What would it be like to be in a radiologist’s shoes? To spend most of my day dealing with images of people: plain black-and-white x-ray images, or speckled images caused by sound waves bouncing off organs, or images caused by dyes outlining arteries and veins, or contrast medium filling loops of bowel, or images reconstructed by computers into cross sections of the body—all without speaking to a patient. The only time a radiologist put his or her hand on a patient was to stick a needle into an artery so as to inject dye for an angiogram, or sometimes to compress a stomach with a lead-lined gloved hand, watching under the fluoroscope as barium negotiated the gastric outlet.

  The “what if? ” question occurred to me often now. What if I was a cardiothoracic surgeon? What if my income was three million a year? What if I was a radiologist with music piped into my office and a stack of images to move from my “in” file to my “out” file, and the certainty of a tee time of 3:45 every afternoon at the country club? I would want the leather chair, of course; the expense was justified. What if I was a pathologist? How would it be to stare at tissue taken from a patient, never seeing the whole patient unless on the autopsy table? Or an ophthalmologist, interested only in the eyes? On the playing field of medicine, with all its established positions and specialized players, I felt increasingly like the man from the moon, the man playing left-out. Nobody dwelled on what it was like to be in my shoes; they were merely thankful that they were not.

  This was a new situation for me. I had always felt I was an important cog in the medical machine. An underpaid cog, perhaps, but still part of the team. The exile I felt had less to do with being an AIDS doc than with the fact that most of my patients were homosexuals.

  A few weeks earlier, a Mrs. Lillian Paez, a well-connected socialite, had called me through an intermediary and asked if she could chat with me. Not at the clinic, but either at her house or at my VA office. I picked my office. She came in the early evening when most people had left.

  I watched through a window as she parked her Lincoln Town Car and then crossed the street to my office. She was wearing a suit that I doubted even Parks-Belk in town carried. There were diamonds in her ears. Her necklace had marks of age, but the pearls it was made of were unmistakably real. “Genuine pearls,” the voice of Vickie McCray whispered in my ears.

  Mrs. Paez wanted to talk to me about her son. He lived in San Diego. “Let me be frank,” she said, fingering the pearls. “My son has AIDS. My son is dying slowly but he is still working. Eventually, I hope to bring him back here when he can no longer manage over there. I love him dearly. But both he and I don’t want anyone to know about AIDS. Cancer or lymphoma is what we will tell people. When my son dies, I want people to remember his life, his kindness, his personality. If they know he has AIDS, to them it will just be another faggot dying. I don’t want my son remembered that way: as a faggot.”

  With her first few words I had been primed to resist this lady, argue with her, be the proletarian doctor and deny her any special treatment—why was her son different? But to see tears in her eyes, to find a rush of hot tears in my own eyes as I imagined my own mother in this predicament, took away all my resistance.

  I cited some examples for her. People who had made the transition back successfully. Who had not hidden what they had.

  She interrupted me: “I sit at dinners where they talk about faggots. Can you imagine how that makes me feel? I want to say to them: ‘Do you know you are talking about my son? Do you know this could be your son and you just don’t know it?’ I know that it won’t change anything. His own father has no idea he is gay, or at least won’t acknowledge it. He doesn’t know his son is sick.”

  “Won’t he know when your son comes back?”

  “We are divorced, so he isn’t around. I imagine when the time comes he will have to know. To him it will be yet another reason why I failed him. He always accused me of babying my son. This will be his ammunition.”

  How could I argue with her? She was right about homophobia. My patient did not exist as a person in the radiology department: He was a cluster of echoes recorded on smoky paper, he was a gallbladder, and finally he was a homosexual who quite possibly had a bug “from the kitchen sink” in his belly. In the hospital it was almost as if he had no existence beyond his label of “homosexual.” The “AIDS” was an afterthought. If he had hobbies, aspirations, foibles and eccentricities, a special talent, these had been discarded in the lobby. Unless they hid their homosexuality, like Mrs. Paez’s son, there was the danger that when they died they would be remembered for being faggots, something less than human.

  Mrs. Paez left my office with my promise to help her son when he came home, help him die at home when it came to that. As I watched her cross the street, I tried to imagine her entering a TAP meeting, tried to imagine her “being real” as Fred would say. I could not. But nor could I imagine my own mother (if life had been different and she found herself like Mrs. Paez in this situation) walking into that meeting.

  THERE WERE FOUR surgical groups at the Miracle Center, a total of twelve surgeons. I had asked Sue McCoy, my surgical counterpart with the University Practice Group, to see Cameron Tolliver, the patient whose ultrasound I had gone over with the radiologist. Sue was in her forties, had gone to medical school and to a surgical residency fairly late in life, after a previous career as a researcher. She had a quiet, unassuming manner. We had worked together on several committees and I thought of her as a careful and thorough physician.

  At one time or another, all the surgeons in town had asked me to see their patients. In turn, I referred my paying non-HIV patients to them for hernia repairs, gallbladder removal, or placement of a Hickman catheter into a vein for prolonged antibiotic administration. I tried to distribute these consultations evenly.

  But now, when any of my HIV-infected patients required surgery, I was faced with a dilemma: Which surgeon should I ask? A surgeon operating on one of my patients was at greater risk of getting infected through a cut or needlestick than I was from simply examining patients. I had tried to be fair about it: I tried to spread my consultations around, trying not to go back to the same surgeon too often.

  Most of the surgeons were older than I, not people that I knew well. There were a few who were my contemporaries. I approached one of these younger surgeons a few weeks earlier when Otis Jackson had needed a Hickman catheter. To my surprise, the surgeon balked, said he would get back to me. And to my greater surprise, his partner, a crusty old-time surgeon whom I had hesitated to as
k, counseled his junior partner to put in the catheter, otherwise he would do it himself.

  Every surgeon I had approached had promptly come to see the patient and did whatever was needed. However they may have felt about being consulted, or about the patient’s lifestyle, they were extremely professional. They seemed less troubled by the risk than I had imagined. Perhaps they sensed my discomfort in having to subject them to risk.

  For my part, I always offered to scrub with them for the surgery, hold a retractor. This was largely a symbolic gesture: Most pundits recommended that only experienced surgical personnel be in the theater when operating on HIV-infected patients, thereby reducing the chances for accidental needlesticks or cuts during surgery.

  Sue McCoy, I knew, had been examining Cameron twice a day, trying to decide whether surgery was urgently indicated.

  I entered Cameron Tolliver’s room. It was permeated with a now familiar scent. It was a fruity odor with a visceral aftertaste that reminded me of a freshly opened cadaver. Cameron lay looking up at the ceiling, his knees pulled up. The sheets around him were soaked and redolent with the same odor. The television was turned off. He was unnaturally still, as if the bed was booby-trapped and the slightest twitch from him could send body parts helter-skelter over the Johnson City landscape. The only part of his body that moved was his eyes. They tracked me from the door to the right side of his bed. He was breathing with rapid shallow breaths, each punctuated with a soft grunt.

  “I want to kick and thrash from this pain,” he whispered, pausing after every other word. “But any time I move, any movement just makes that pain worse.”

  The pain for which I admitted him, pain over the gallbladder area, had initially subsided on antibiotics. Now, after twenty-four hours, the pain was back. His temperature had gone up during the night to 102° Fahrenheit. His white blood cell count had climbed from 7,000 the day he came in to 12,000. His pulse rate was now 112 beats per minute, and it had hit 160 beats per minute at the height of his fever. His blood pressure stayed steady.

  Cameron’s mouth was dry from his rapid shallow breathing. But the turgor of his skin when I picked it up and let it go was excellent—he was not dehydrated. His urine output on each eight-hour shift had averaged over a liter, good evidence that he was well hydrated.

  I laid the diaphragm of my stethoscope gently on all four quadrants of the abdomen, listening at each site for twenty seconds. There was almost complete silence, only the whoosh of blood rushing through my ears. The normal bowel sounds were gone and replaced by high-pitched and infrequent tinkling sounds. The loops of bowel had ceased their normal peristalsis so as to wall off the inflammatory process, keep it from spreading.

  I rubbed my hands together to warm them. I gently brought the palm of my right hand down over his lower abdomen, beginning palpation away from where he complained of pain. I could feel no mass. The spleen was not palpable. But he was still tender in the area near his gallbladder. When I pushed down and then rapidly lifted my hand away, the ripple it sent through his abdomen caused him to wince—he still had “rebound” tenderness.

  There comes a point at which you have to open up an abdomen—do a laparotomy—so as not to miss a potential surgical catastrophe. A surgeon who finds something wrong in the abdomen only 60 percent of the time is being too adventurous, opening bellies that he or she should probably wait on. On the other hand, a surgeon whose batting average is 100 percent is being too cautious, waiting till it would be obvious even to a layman that an abdominal catastrophe is occurring. To wait that long is to allow common conditions like appendicitis to become very advanced and complicated by rupture and abscess formation.

  I stepped outside and paged Sue McCoy. She turned out to be just down the hall. We conferred. She said she had been trying to find me. She too had decided a few minutes ago that we could wait no longer. Cameron needed to go down to the operating room. We both went in to tell Cameron.

  When, later, I made the offer to scrub in at surgery, Sue said, “Good, see you down there!”

  I dashed home for a quick bite and a few minutes with the kids. I told Rajani where I was going. My tone was matter-of-fact. I told her the truth: I was scared but I felt obliged to be there for my patient. But her discomfort at what I was doing was mounting; she wanted to talk to me. Only the fact that I had to rush back to surgery postponed our conversation.

  A half hour later I was scrubbed and gowned, standing on the left side of Cameron, my hands clasped together in papal fashion, trying to stay out of the way until needed. The operating room nurses, notorious for being a tough breed, had been very solicitous, helping me with shoe covers, talking me through the ritual of hand scrubbing which I had forgotten, reminding me to scrub for a full five minutes, to only let water run down from my hands to the elbow and not the other way around, to come into the OR with my arms raised. Within the OR, the nurse handed me a sterile towel to wipe my hands and then helped me with gown and gloves. Sue and a young surgical resident slit the abdomen down its center, parting the rectus muscle and exposing the glistening peritoneal membrane which, when opened, revealed the shiny yellow fat globules of the omentum and beneath it loops of bowel. They had opted for a midline vertical incision rather than one under the right rib cage, because we were not sure the gallbladder was the seat of the problem; the midline incision allowed better access to other organs.

  The incision was lengthened, retractors placed. Dark red drops of blood pouted at the tip of arteries that had been sealed with bursts from the electrocautery. The smell of burned flesh rose to my nostrils. The gold fat globules in the subcutaneous tissue formed a bright wreath around the incision which had now been pulled into a wide oval. The liver presided majestically over the upper abdomen, its crimson-cardinal edge like an arched curtain over the organs below. Beneath its undersurface, just peeking out, was the dark green gallbladder. Sue put her hand in and felt the gallbladder, massaged it between her thumb and fingers the way you would feel a coin purse. The purse was empty: there were no stones in it and none in the duct that led from it into the duodenum.

  She stepped back and told me to feel around, and I inserted my hand into Cameron’s belly. My yellow gloved hand, now streaked with blood, looked as if it belonged to someone else as I felt the gallbladder, ran my fingers across the smooth liver. She nodded at me to go on and so I felt the spleen, felt the loops of bowel and the strong thump of the aorta behind. There was blood on my hands, blood all around. As internists, how often our hands probe the surface of a belly, imagining what is below, stumbling on the surface like a skiff over the ocean beneath which all sorts of treasures lurk. I stepped back reluctantly.

  Now Sue systematically examined the rest of the abdomen, palpating the spleen, the liver, feeding the small bowel loop by loop through her fingers in search of any abnormality, feeling the cecum and the appendix and the colon.

  “There is nothing I can see wrong. No mesenteric lymph nodes. The appendix looks okay. The gallbladder looks sort of okay.”

  They irrigated the abdomen and now started a second careful examination of every inch of bowel, of all the organs.

  Sue looked at me. “Well, at least there is no bowel perforation or strangulation. I’m going to go ahead and take out the appendix and gallbladder.”

  She removed the appendix swiftly and surely, tying a purse-string knot at the base of the cecum that allowed the stump to pucker in and be buried. Then she packed the bowel to one side, changed places with the resident, allowing him to remove the gallbladder from its bed. She hooked an L-shaped retractor under the liver and lifted up the free edge of the liver and handed the retractor to me, indicating with her hand over mine how much tension I was to apply. Then Sue and the resident dissected the gallbladder free of the undersurface of the liver. He tied off the artery to the gallbladder, tied off the cystic duct and then delivered the gallbladder into a kidney basin.

  While the resident closed up, Sue and I slit the gallbladder open at a side table. The bile within was
dark green, almost black. We looked for stones on its bile-stained insides; there were none.

  I stripped off my bloody gloves. There were some streaks of blood on my gown. I remembered my final year of training in India, my surgical rotation: We “junior house-surgeons” did the sebaceous cyst removals, the circumcisions and occasionally the hernias and hydroceles. The surgical postgraduates fought over the stomach ulcers, the thyroids, the cancerous breasts. On my last day on the general surgery ward, I was rewarded for good work by being allowed to do a gastrojejunostomy: hooking up stomach to jejunum and bypassing an ulcer in the duodenum. A surgical postgraduate on the other side of the table had walked me through it. I remember stepping away three hours later, blood on my gloves, blood on my gown, a postcoital kind of weariness and euphoria washing over me, understanding the opium that drove people to become surgeons. It did not sway me—I was certain I wanted to be an internist.

  I changed back into street clothes in the men’s locker room. When I came out, Sue was in the surgical lounge where she was dictating her notes.

  I waited to chat with Sue.

  When she was done dictating, we talked about plans for Cameron’s care. We agreed that she would take care of him on the surgical service for twenty-four hours. At that point, if all was well, I would take over.

  “Thanks for scrubbing with us,” she said to me. “It was kind of reassuring to have you there. I mean, despite everything the CDC says, if you listen to that Lorraine Day woman long enough, you get very scared. To see you there made me feel better.” (Lorraine Day was the orthopedic surgeon who at one time worked at San Francisco General; she preached that the government was hiding AIDS facts, that the virus was much more infectious than anyone realized, that for all you knew you could get it in a salad bar if a gay cook had prepared the food and accidentally bled into it . . .)