Year of the Intern

by Robin Cook

  My aneurysm had been scheduled for his aortogram at eleven-fifteen, and I went down to see what was happening. Stepping into the fluoroscopy room, I saw that the chief resident was in the final preparations for the study. "You're ten minutes late, Peters. I could have used you to help get the catheter into the aortic bulb."

  "And I would have been here, but I had to scrub for another case." I consciously withheld a "thanks to you."

  "Well, here's the catheter position. Put on a lead-lined apron first. This fluoroscopy puts out a lot of radiation. Gotta protect the old gonads."

  Following his advice, I took one of the heavy leaded aprons and put it on. By stepping behind him I could see the fluoro screen. As the lights went out, the fluoroscope came on automatically with a low resonant dick. Then image was extremely faint, as usual. In order to see a fluoroscopy well, you ought to adapt your eyes by wearing red goggles for thirty minutes or so beforehand. I couldn't tell very much about the aneurysm patient on the fluoro screen, because I hadn't had the chance to dark-adapt my eyes, but I could distinguish the heavy radiopaque stripe on the catheter.

  "Here's the end of the catheter." The chief resident's pointing finger was silhouetted by the light from the screen. "If s in the aorta just above the heart. See it jump with each heart contraction?" I could see that with no difficulty. "Now, we went to inject enough radiopaque dye into the artery to get an image, and to do that we have to use the pressure injector." He indicated a small machine that looked something like a bicycle pump turned on its side. It had three or four stopcocks positioned on the end—I thought one or two should have been sufficient to prevent a mishap. "All we do is push this handle, which shoots the dye very rapidly into the heart, at about 400 psi. At the same time the Schonander camera will be shooting X rays at a rate of one every half second for ten seconds. We'll watch on the fluoro screen."

  The chief resident swung into the final preparations, calling to make sure the X-ray technicians were ready and positioning himself behind the arm of the pressure injector. Desiring all the protection I could get, I squeezed in behind the lead screen with the X-ray technician, who was a solid little thing. We watched through the quartz window.

  At a yell from the chief resident, the X-ray technician started the Schonander camera, which cranked and pounded, taking X ray after X ray in rapid succession, while die chief resident plunged the pressure injector all the way down. The dye shot from the injector into the stopcocks, and then, instead of being propelled into the patient's heart, rose in a graceful geyser to the ceiling, splattering there and running a little way along before dripping down onto the chief resident, the patient, and the mass of machinery. The chief resident had forgotten to open the last stopcock. As for the patient, he just lay there blinking and looking around, trying to figure out what sort of strange test this was. The chief resident was in a state of shock blending rapidly into exasperation. Since the whole procedure would now have to start over and I was already a little late for the cholecystectomy, I took the opportunity to make an unobtrusive exit and hurried back to the OR.

  Working with a real professional is different in every way from assisting a Hercules or a Supercharger, and Dr. Simpson was the best the hospital had. With the resident on one side of him and me on the other, we scrubbed together, talking and joking. Simpson told us the one about a Columbia professor who discovered a way to create life in the laboratory. Everything went well until his wife caught him.

  A simple joke—perhaps, on reflection, not even a very good one. But in the context of my hours with Hercules, the image of dye all over the fluoro-room ceiling, and my tiredness, that joke plunged me into hysterical laughter. We were still chuckling as the three of us entered the operating room, where the atmosphere changed immediately to one of congenial concentration. Ready to go, we were still light toned, but nevertheless intensely interested in the task ahead.

  The nurse handed Simpson a scalpel. Interesting how he started an operation. There was no pause. The knife shot in to the hilt and zoomed cleanly, diagonally down the abdomen. He didn't pause to catch bleeders with hemostats. "Why scratch around like a chicken?" he would say, completing the incision rapidly, with the same sharp, purposeful dissection, as the tissue fell apart. The resident would then pick up the tissue on his side, the surgeon on the other, both using tooth forceps, and with a final flash of the knife they were into the abdomen. Only then were a few bleeders caught and tied. No more than three minutes from skin to peritoneal cavity. Perfection.

  This time, however, Simpson didn't make the first cut. He surprised us by handing the knife to the resident instead. "Your gall bladder," he said. "One false move and you'll be doing enemas for a month." Under his expert eye, the same kind of incision was made, at just about the same speed. The surgeon explored rapidly inside, then the resident, then me. Stomach, duodenum, liver, gall bladder (I could feel the stones), spleen, intestines. The examination was gingerly but thorough; with your arm elbow deep in someone's abdomen, you tend to be gingerly. I told Simpson I was having trouble feeling the pancreas. He explained a landmark and a bulge. Then I felt it.

  Using Simpson's technique, the resident carefully placed the saline-soaked white towels that are used to separate the gall bladder from the mass of intestines. I was given the usual retractors. At a suggestion from Simpson, the resident moved down a little, enabling me to see into the wound. It all went rapidly, with encouragement but no manual assistance from Simpson. The gall bladder came out cleanly the base was closed, and then the skin, all within thirty minutes. Feeling good now, I congratulated the resident on our way to the recovery room. He had done a professional job.

  With thirty minutes between cases, Simpson and I went down to see several of his patients, one of whom, a gastrectomy, I was following closely after having helped with the surgery. I had been given total responsibility for writing orders on the case, although I tried to follow Simpson's preferences, which, I knew by now, were sound and sensible. When he changed one of my orders, as occasionally happened, he invariably wrote out a short explanation, an opinion on some drug or procedure. He was a born teacher.

  After our trip to the ward, we put on another set of clean scrub suits and began to scrub again, in the same bantering way, this time without hysteria on my part. I decided, on reflection, to switch to Betadine for this scrub; its pale yellow color offered a bit of variety, after the colorless phisohex we usually used. Entering the OR, we observed the usual hierarchic routine. A towel went first to Simpson, then one to the resident, and then one to me. It was the same with gloves.

  As we huddled around the patient, the nurse handed Simpson a scalpel, and to my utter confusion he handed it on to me. "Okay, Peters. Get the gall bladder, and get it right the first time or I'll remove yours without anesthesia." Obviously, I had never done a cholecystectomy before, though I had seen a hundred or more, and this development was definitely not in my imagined scenario. I had looked forward to another session as interested spectator, watching two professionals (the resident had come of age) work together. Now, however, I was to be not a spectator, but a participant—indeed, the chief actor. Suddenly the man on the table and the scalpel in my hand took on new reality. Inwardly awash with uncertainty, I knew that if I hesitated now, I might be too scared ever to try again. I somehow conquered a tremor that threatened to develop in my right hand, grasped the knife firmly, and tried to duplicate Simpson's first slice into the top of the abdomen, going straight in, up to the hilt, then coming diagonally down the blade at a ninety-degree angle with the skin. I wanted to please Simpson as a son wants to please his father.

  "By golly, there's hope for you yet," he said in jest, not knowing how sweet the words were to me. As I repeated the maneuver, muscles and fat parted and, retracted. Some bleeding followed, but not much.

  "Forceps." The nurse gave them to me, and a pair to the surgeon. I lifted one side of the incision, he the other. At this point we were very close to the thin, peritoneal membrane that forms the lini
ng of the abdominal cavity. We were lifting now to protect the underlying organs as I pushed in the blade of the scalpel. Pop! A hole appeared in the abdomen, and I let go of the forceps.

  "Keep the forceps," Simpson suggested, "and cut while you can see." I tried, going carefully because the liver and intestines were clearly visible in the widening incision. It worked fine. Then, for the lower end of the incision, I had to change the technique. Dropping the forceps, I slid my hand into the wound and opened the rest of the peritoneum by cutting between my fingers. My heart was racing. I didn't feel tired now, nor did I notice the clock, the radio, or the anesthesiologist. I was scared but determined. Simpson felt around, then I did, then the resident, and the resident took the retractors as I moved down to give him an open view if he wanted it. I also tried to follow Simpson's technique with the abdominal tapes. He helped me with the last one, and then with his hand he rolled the duodenum far enough that I could see a smooth curve of tissue stretching from the top of the duodenum to the gall bladder. After clamping the gall bladder and pulling up, I used the Metzenbaum scissors to push down the delicate tissue. An artery was in there somewhere, the cystic artery, which carried blood to the gall bladder. Mustn't cut it.

  The muscles of my neck were hard as rocks as I bent far over, trying to see clearly. Simpson told me to straighten up or I wouldn't last fifteen minutes. The artery appeared—about the usual size for a cystic artery—and I isolated it with a gall-bladder clamp. A tie went around, and I took the ends. First throw. I ran it down with my right index finger. Good. Second throw. Down. How much tension should I put on the thread? That was enough; I didn't want it to break. One more throw, just to be sure. With the help of the gall-bladder clamp, another suture went around the cystic artery. This time I had to make the tie way down, close to the hepatic artery going to the liver. The cystic artery branched from the hepatic artery, and by pulling slightly on the suture already tied around the cystic artery I could see the wall of the hepatic artery. In fact, I could even see the branch going to the right side of the liver. That made me feel better, because there was always the danger of confusing that bugger with the cystic artery and tying it off.

  I was quite concerned about this second knot on the cystic artery. It was the single most important tie of the whole operation. If it fell off some days later, the patient could bleed to death internally. With this in mind, I ran down the first throw and then peered into the hole. It looked okay. Involuntarily, I glanced at Simpson, who didn't complain. So I finished it, and then cut through the artery between the ties, beginning the isolation of the gall bladder.

  Next came the cystic duct, through which the bile normally flows. I handled it the same way, tying it with two sutures and then cutting between the knots. Once the gall bladder was isolated, I tensely ran a scalpel lightly around its bed so that just the outside layer of glistening tissues parted. With the scissors, I began to lift the gall bladder away from the liver.

  "He's making this look difficult," kidded Simpson.

  "If he takes much longer, the thing will develop gangrene." I hardly heard him. The whole operation was only twenty-five minutes old.

  With one more gentle cut and a tug, the gall bladder came free. I plopped it in the pan proffered by the nurse. With her other hand she gave me a needle holder with 3-0 chromic suture. Picking up the tissue from the edge of the gall-bladder bed and pulling it over the exposed hepatic duct and right hepatic artery, I took a stitch and tied it down firmly. Too firmly. The suture broke. Another, same place, tied this time with more care, less tension. Then with a running stitch I closed the gall-bladder bed.

  After removing the towels used to separate the gall-bladder area from the other internal organs, I began to close. The nurses started their sponge and instrument count to make sure I hadn't left anything behind. All was in order. Carefully I identified all the levels of the abdominal wall, especially the tough fascial layer, which had retracted back out of sight. Stitch after stitch went into the wound, with both the surgeon and the resident helping me tie. I dug the curved needle into the lower side, took it out through the incision, repositioned it with my left hand, then through the upper side. Layer by layer I closed the incision, as if shuffling a deck of cards, watching them snap together and overlap. Finally the skin. When it was over a soaring confidence came over me, like the feeling you get at the end of a good wave when your board breaks out of the white water. As I snapped off my gloves, the resident returned my earlier compliment. The world was mine.

  Accompanying the patient down the hall to the recovery room, I was still on a high. Two nurses took charge of the patient while I wrote postoperative orders and dictated the operative note. Then the fatigue came back, hard. I was hungry, too, and I decided to eat, because I hadn't had anything but those two slices of bread since supper the night before, nineteen hours ago; it was 2:00 p.m.

  Outside the hospital it was pouring rain; had been all day, I guessed, since water was standing in the low spots. The sky swirled with gray clouds chased in over the island by strong kona winds. It was raining so hard I could barely see the coffee ship a hundred yards away. As I ran the breeze ruffled the puddles of water collected under the overhang. I felt my luck go off a little when I saw Joyce across the room, and, sure enough, she immediately came over to join me. With plenty of other people near us busily talking about the rain, the Hula Bowl, and what not, Joyce said little at first, which suited me. Then, as if by signal, everyone else left and Joyce started in.

  "Have you been thinking a lot?" she asked.

  "About what?" I was curious.

  "You know, about us, like you said you'd do."

  "Oh, about us. Yeah, I've been giving it some thought," I said.

  "Well, I have, too," she added, sitting up a little. "And I think we should be more open with each other."

  "You do, huh?" I was slightly sarcastic, but not enough for her to notice.

  "We just haven't been telling each other enough about our feelings and our thoughts," she added.

  She was wrong there. She had been telling me too much, especially about how terrible it was sneaking down those back stairs. Uneasily, I realized she was only a step from proposing an instant cure to sneaking around—marriage. She was slightly out of control.

  "You had been telling me what was on your mind pretty well," I said. "You never stopped talking about those stairs and how lousy everything was."

  "Well, that was getting very uncomfortable," she said righteously.

  "Uncomfortable. Well, that’s true. Why don't you do something about your Miss-Apples-and-TV so we can go to your apartment like normal people?"

  "My roommate has nothing to do with it."

  "Your roommate has a lot to do with it. If it weren't for your roommate, we could stay over there at your apartment, and you wouldn't have to sneak down the stairs."

  "You don't care about me at all," she said petulantly.

  "Of course I do, but that’s not the point. If you—"

  "It is the point," she interrupted.

  "You're changing the subject," I protested.

  "Well, it's the only subject I'm interested in," she said staidly, standing up and scraping back her chair. "Anyway, I've decided you can stop thinking about us, and drop dead." She strode out indignantly.

  Drop dead. A great suggestion. Actually, the idea held a kind of morbid appeal. I was that tired. With Joyce gone, the room moved away from me suddenly. A lot of people were still sitting around other tables, but not a soul was there with me. The sounds of a hundred voices mingled, all distant and incomprehensible. Staring through the window at the rain and the gray scudding clouds, I chewed absent-mindedly, overcome by loneliness. Nothing remained of that good feeling after the gall bladder; in its wake, I was simply drained of all emotion. Looking at the clock, I realized I had been going full steam for thirty hours. I thought about the clinic, and that I should go over there. Interns are supposed to help with outpatients in their "free time." But in my state I wou
ldn't be of any use. To hell with the clinic.

  Raindrops danced around the overhang as the wind whipped them into sheltered areas. It was surprisingly cold. When tired, the body cannot tolerate much in the way of temperature variation. So the chills I felt coursing through me were probably more a product of my physical condition than of the weather. I hurried along, concentrating totally on my bed, anticipating the pleasure. All interns develop an extraordinary appreciation for simple things others take for granted—free muscular movement; the right to relieve an itch, void one's bladder, or empty one's bowels; more or less regular meals; a decent amount of sleep. In bed, I felt my body sinking, growing tremendous and filling the room, until my huge body and the room gradually merged, became one, and I slept.