Writer, M.D.

by Leah Kaminsky

  Beauty

  GABRIEL WESTON

  From my earliest days at medical school, I found surgery not just practical but beautiful. Dating from that first operation, when I had seen my tutor’s brother replacing a cranky hip joint with a new one, this sense of surgery’s fine aesthetic gathered momentum during the early years of my clinical education. Compared to the limitlessly difficult and ambiguous world of medicine, surgery was diagnostically clear. Relatively few surgical diseases were described, all of them concerned with quite definite abnormalities. Tumors, fractures, clots. Empirically true, often touchable facts.

  The operations designed to treat these frailties were also lovely in their combination of regularity with a magical kind of artistry. In surgical textbooks, I found difficult procedures dissected and laid out in stages. They suggested a craft which was repeatable, reliable, and always dramatic. This last fact mattered to me. Being a surgeon just sounded so much more impressive than being a physician.

  But the feature of surgery that struck me as most beautiful was its almost-military adherence to the principle of order. Surgeons started their days an hour earlier than their medical counterparts, and did ward rounds quickly and efficiently. Diseases were easy to diagnose, leaving time for the careful planning of classic procedures, tweaked to suit the individual patient. These operations were then performed with marvelous precision. Cure was not guaranteed, but decisive surgery was often a person’s best chance of reaching that goal.

  I observed the objective correlative of this philosophy in the immaculate layout of the operating theater. The geography was of a main room with annexes. Most important of these was the anesthetic room, where the patient goes to be put to sleep so as to avoid the stress of seeing where he or she is going to be cut open. The prep room is another antechamber, where the scrub nurse sorts through the pack of instruments, each operation with its own pack, with its own designated tools. Then there is the alcove for scrubbing, with its zinc sink and shelves piled with plastic-packed gowns and gloves in all sizes, in waxy paper envelopes.

  I had enjoyed watching the choreography that animated this space many times. The way the anesthetic doors would open to deliver a bedded, tubed patient at the same time as the scrub nurse appeared with her trolley, like a hostess bringing out a science-fiction tea. And how the surgeon would enter center-stage, arms held aloft, gown billowing like a gust-filled kite.

  I suppose I was in love, seeing beauty all around me in my new surgical world. It would not take long for me to see that surgery was not always rosy, not always controllable and pretty.

  I was due to spend the evening in Accident and Emergency (A&E), shadowing a senior house officer (SHO) on his night shift. As a mere student, I had no responsibility. I was there to learn what I could, and to assist the junior doctor I had been assigned to, in whatever way he saw fit. To get a feel for this environment that would soon be like home.

  That evening I was with a junior doctor called John. He was a conventional tubby guy, but I remember how attractive he seemed to me. After all, he was a real doctor and, although I was due to become one within months, the chasm of experience and style seemed huge between us. It’s funny how doctors go from being really sexy when you’re not one yourself to rather unsexy when you are.

  Well, he was busy and at a loss for what to do with me. So he suggested that I go and take a history and do an examination on a man he had just seen, who had come in with abdominal pain. As John was telling me what to do, he was busy organizing an intravenous urethrogram on the same patient, a scan which I knew was routinely performed on those thought to have a kidney stone. I felt disappointed that I already knew the diagnosis on the person I was about to see. What was the point in reading an Agatha Christie story if you already knew who the murderer was? I thought, as I headed for cubicle 5.

  I paused just outside the cubicle curtain, to collect myself, and to check, in my Oxford Handbook, vade mecum of all medical students, what questions I needed to ask someone with abdominal discomfort. I saw the usual list of factors germane to any sort of pain: onset, site, severity, duration, intensity, character, relieving or exacerbating factors. Plus the relevance of bladder and bowel habit. Then, conscious of trying to look less awkward than I felt, I went in.

  The couple I introduced myself to were Mr. Cooke and his wife. He was sitting on the bed, and she was sitting on the chair beside it. Despite being in his late sixties, he was trim. Sitting back at a 45-degree angle had not produced a little roll of fat at his belt line. His face was not the florid hue of the cardiopath; his measured breathing suggested good lungs. Only a double furrow on his brow indicated discomfort. That and the fact that his eyes were closed as if he was trying to narrow his sensory field. His hair was gray and thin, but looked windswept rather than straggly. He was wearing khaki trousers. Not genteel chinos, but made of something thicker and more practical, like canvas.

  On his top half, he wore a plaid shirt whose sleeves were rolled to just above the elbow so that I could see slim but sinewy arms, finished with large, strong hands. His knuckles were like big marbles, and his veins looked like tree roots, as if they wouldn’t be soft if you pressed them with a finger of childlike curiosity. He was a slight man, but valor vied with slightness to be noticed first.

  Next to him, his wife appeared almost buxom. She had a good bosom, and it had that stiff, unified look that made it hard to imagine that it was composed of two soft breasts. She had brown hair that was only just beginning to gray. It reached her shoulders, and some of it was held from her roughened cheek with a clip, which might have looked absurdly girlish but didn’t, because her eyes, which met mine the instant that I walked into the room, had a shiny sort of wisdom in them.

  It was hard to see exactly what she was wearing, since the folds of this merged into the creases and swaths of that, but it was all dark and soft, in grays and greens and browns, so that she looked wholesome and foresty. She had a handbag by her feet which stood up by itself. One of the handles was upright, and the other had collapsed to one side. And on her lap she had one of those old mauve-and-white Penguins that they now design mugs from, and this one was Virginia Woolf’s A Room of One’s Own. Mrs. Cooke looked as if she had had such a room all her life, or as if she had never needed one.

  Because she was looking at me, I introduced myself more to her than him. He had opened his eyes when I entered the cubicle, but had closed them again when he heard the words “medical student,” although with a kind smile. I might have felt put out, but Mrs. Cooke, in the same measure that her husband had dismissed me, welcomed me with her response. She gave me the kind of look that a governess might give a child that has just washed its hands adequately, and she closed her book. She put her book in her bag and then sat up, hands in lap, to give me her full attention. Her hands, too, looked strong. The skin on them was chapped like a gardener’s. I thought briefly of the minute, unfair discrepancy: that a man’s strong hands are alluring, but that beautiful hands in a woman are those that have done nothing.

  She was patient with my questions, but we both knew that a diagnosis had already been made, so the interview felt sluggish. I dreaded the prospect of having to examine this dignified man in front of his owl-like wife. I didn’t like to think of touching, let alone hurting, the abdomen that lay under that soft shirt. An abdomen which, in my imagination, grew intensely white and private.

  So I was grateful when, by some happy conversational torque, things turned from the medical matter in hand to a discussion of poetry. I cannot remember how this happened. It turned out that Mr. Cooke was a retired professor of English literature, and once we left the subject of his own cranky body behind to turn to what interested him most, he became quite animated. His wife explained that they were engaged in a marriage-long dispute about the comparative merits of Augustan versus Romantic poetry. It must have been a sort of harbor, for they began to banter lightly about it now, he sometimes opening his eyes to praise Keats or Shelley, or especially Wordsworth,
over her favorites, the champion of whom appeared to be Alexander Pope.

  Mrs. Cooke’s face had softened, and she was saying, “Oh, for goodness sake, Charles, all those ghastly demonstrations of feeling. All that narcissism. How can you …”

  And he was chuckling, despite his still-closed eyelids. He reached for his wife’s hand and found it easily. Grasping it in midair, he gave it a sort of playful shake up and down while he addressed me with, “My wife loves Pope with all his strictures and his order. Because she finds the chaos of the really great poets a bit too scary.”

  I noticed their hands, which stayed within the joint grip they had made, for a few seconds after his last quip. Her scuffed red skin. His bony fingers. The difference between them. Then they had to let go because of the discomfort of his having to extend his arm off the bed with no support.

  I was trying to think of a way I could join in their conversation when Mr. Cooke’s face suddenly seemed to fold in on itself, and an exclamation of pain rang from him. There was sweat on his face where there hadn’t been before, and he didn’t look good. I got up, tripping slightly on my chair, and rushed to find John or a nurse.

  Within two minutes, Mr. Cooke had been wheeled into Resus, his wife as near to him as she could get, given the sudden interest of all the doctors and nurses taking him there, expediting this short journey. The space was compassed in a matter of seconds. Then Mr. Cooke was being hooked up to all sorts of things, and people were saying how low his blood pressure was, how tachycardic his pulse was. Even in my student ignorance, I could tell he was in hemodynamic shock, he looked so gray and unwell.

  A senior A&E doctor, realizing that the diagnosis of ureteric colic had been wrong, performed a quick abdominal ultrasound right there, and this showed that Mr. Cooke had a leaking abdominal aortic aneurysm. Unless he was taken immediately to have this most major of all blood vessels in the body repaired, he would not survive the next hour.

  At that point, I noticed several things at once. A nurse, calling theater to prepare them. The sight of John in the background, looking as if he was about to cry. The A&E registrar telling me that they needed extra hands in the theater, that none of his juniors were available, and that I should go and help. The bang of the A&E doors as Mr. Cooke’s bed was bashed through them to take him to the theater. The sight of his wife, still relegated to the outer circle of bodies, standing in Resus, as the bed and her husband disappeared down the corridor. Trying to compose herself. Waiting for someone to tell her what she should do, where she should go.

  I took a shortcut to theater, and changed hurriedly. They need me! I thought as I grabbed a blue cap from the cardboard box on top of the lockers on my way out of the women’s changing room. Because I was alone, I allowed myself to feel the great excitement of the surgery I was about to assist in. I knew the operation would be dramatic, but had no doubt it would work. I was glad to be a part of this drama, and felt good even to be wearing surgical scrubs, a sense of pride I confess I still have whenever I don this costume, even since it has become my habit. I slowed my step as I approached the emergency theater, so that I wouldn’t look breathless and uncool when I got there.

  What I saw when I walked into the room shocked me and made me feel ashamed of my recent excitement. There was a scrum of blue backs leaning over Mr. Cooke on the operating table. He was neither undressed nor asleep, but the men in blue were working on him. One was cutting his shirt off, and others were leaning on him, forcing him to lie down, despite his efforts to rise up and scram. I saw his slim, muscular belly, that part of him I had been reluctant to expose half an hour before, and I noticed the little red Campbell de Morgan spots on its skin, just like my dad has.

  Two men took one arm each. Other helpers brought armrests, which were fixed to the side of the operating table with large screws. Then Mr. Cooke’s arms were forced down at his sides, an immoral arm-wrestle, one man fighting two. Once overcome, his arms were strapped in position like you sometimes see in old films about madhouses.

  And there was the most dreadful noise. Mr. Cooke, previously so self-contained, was roaring like a bear. Then, as he was defeated, loud man-sobbing. And then this patient, pinned down in a position that reminded me of the Crucifixion, was attacked again, from another angle. An anesthetist moved in unseen from north of his head, and his futile flailing started again as he felt the insult of a thick needle being pushed into one of his bulging neck veins. This was the central line, through which he would be monitored, as well as the conduit for receiving drugs and fluids.

  At the same time, two surgeons were daubing his narrow front with brown Betadine in massive painty sweeps. Mr. Cooke’s legs were kicking a bit and his eyes were rolling all around, their luminous whites blindly scanning the activities taking place upon his powerless body. I didn’t know who either of the surgeons was; only that one was a consultant and one a registrar. They didn’t know who I was, either, but I was asked to scrub and became one of two assistants. I was told where to stand, on the patient’s right-hand side, next to the other helper. On the opposite side of the table were the vascular consultant and his registrar.

  The operation began with the swiftest laparotomy incision I have ever seen, the very first I had witnessed at that early stage in my training. In one concerted movement, the consultant literally sliced Mr. Cooke open, from xiphisternum to pubis. His proficiency was marvelously apparent to me: his decisiveness, his knowledge of exactly how much pressure to apply to the large blade to penetrate skin and subcutaneous tissue, without harming any important underlying structures.

  With another single effort, the boss hoisted the whole gut out of Mr. Cooke’s abdominal cavity and dumped it unceremoniously on my side of the table. This forced me, and the guy I was standing next to, to huddle together, to form a barricade with our two adjacent bodies, to stop the snaking mass of small and large bowel from slipping between us, or around either of us, onto the floor. Arms outspread, we held its writhing bulk, and I will never forget the eerie movements it made, vermiculating in our joint embrace.

  Looking down, I peered into the trough of Mr. Cooke’s emptied abdomen, and could see it filling with blood so fast that the outline of the gushing source was visible beneath the red meniscus. Like when you fill a paddling pool with a hose and it’s half full, and you can see a knuckle shape on the surface just above where the hose is. I had been given two huge suctions, and was holding their broad snouts into the crimson depths, one in each hand. These pipes were doing such a strong job that I could feel the pull of them sucking at the blood, and I could hear no milkshake-slurping noise from them; they were not wasting time sucking up a cocktail of air with the fluid, they were just hungrily sucking blood.

  For the next minute or so, nothing seemed to happen. The clearing of blood could not keep up with the rate at which more flowed from the leaking aorta. I was remembering, from my cadaveric dissection days, the first time I had seen this enormous vessel. It is as thick as a walking stick, and stands plumb in the center of the body. It even has the same handle-shaped curve as it leaves its origin in the heart. From there, it travels all the way through the chest and abdomen down to the pelvis, where it bifurcates into the leg-supplying iliac arteries. I knew from my recent studies how few previously undiagnosed leaking aortic aneurysms are survived.

  As if abandoning hope that he was ever going to get a clear view, the consultant splashed in, holding a weighty instrument. When his hands resurfaced, they were empty, because he had used this instrument to clamp the aorta. Then he asked for the Dacron graft, a piece of tubing to replace the leaking bit of vessel. This looked like one of those concertina-type tubes that plumb washing machines. I was given a huge retractor to hold to keep the abdomen wide open, and I would remain like this for the next three hours.

  During that time, repeated attempts to make the graft work failed. Each time the boss undid the clamp, to check the patency of the anastomosis, blood poured into the abdominal cavity again.

  I confess that, whe
n at four in the morning the consultant announced there was no more he could do, my main feeling was relief. The hours in theater had piled up against the thirty minutes or so I had spent with Mr. Cooke in A&E, so that my short connection with him felt out of date. So that any sense of sentiment I might have had had been eclipsed by the drama of the night. And even the drama now felt jaded. I was just tired, and my arms hurt from holding the retractor for so long.

  No one had spoken to me during this theater episode; so, once we had all stepped back from our meddling, it was easy for me to leave quickly. I didn’t want to see Mr. Cooke’s blood brim over, or to hear it disrupt the silence of new death with its splish-splash on the floor.

  After changing, and on my way out of the theater suite, I happened to pass the relatives’ room. Through the window, inlaid within its wooden, school-style door, I could see the broad back of the vascular consultant, a trapezoid imprint of sweat on his scrub top. And then I heard the sudden, uncontrolled noise of Mrs. Cooke’s first exhalation of grief, as horrible as the last sounds her husband had ever made, while struggling to resist the anesthetic. Unheard by him, as he had been by her. Standing outside the room, outside of that immediate extreme zone, I felt embarrassed by the noise before it saddened me. In the way that the sound of people having sex in a nearby hotel room might embarrass you before having any other effect.

  Then I saw the top of Mrs. Cooke’s head, mostly obscured from view by the consultant’s shoulder. She had got up, and she must have been hitting his chest because I could see his back shaking a bit, and I could see movement from her shoulder. I was afraid to see her face. I was afraid she would see mine, just gawping there through the window. And so, since it was not my grief and had not been my operation, since I was feeling no ache from personal loss or personal failure, I walked on and I walked away. I went home, and I never saw any of those people again.