by Robin Cook
The abscess was small when I began, no more than a pimple. Now it was enormous, covering most of the left arm and growing. No matter how much I cut, more appeared; now it crept toward the shoulder. Behind me, Hercules was whispering to the Supercharger, "He'll never make it. Neither will the patient." For encouragement, I looked toward Simpson, who said, "Get it right the first time, Peters, or it's Hicksville for you." In one final, desperate effort, I slashed to the bone through tissue, and to my horror I severed the ulnar nerve, immobilizing the hand forever. Time's up, I thought, as the bell rang; failure! It was, of course, the telephone. I leaped to answer it, still half in the dream and confused by the light. Had I missed rounds? No, they weren't until five o'clock, and my watch indicated three. It was surgery. I had been put on a case scheduled to start in fifteen minutes.
Hanging up, I slowly regained orientation. Why should I have waked up in such a state of terror? Then I connected the dream with the incision and drainage I had done yesterday on a huge elbow abscess. After opening the abscess with a sharp blade, causing a spontaneous flow of pus, I had pushed in the tip of a hemostat clamp to insure good drainage. But the abscess was much deeper than I had expected; it seemed to extend to the area of the ulnar nerve. So I had cut down and down, never truly getting to the bottom of the abscess and finally quitting for fear I would cut the ulnar nerve, if I hadn't already. Anyway, I decided to stop by now and check the case on the way to surgery.
The fright reflex had gotten me out of bed, but then my state of physical disintegration began to finger its way back. After having been up for so long, sleeping less than an hour just made everything worse. Nothing about me seemed to work right; I felt dizzy and slightly nauseous when I stood up after putting on my shoes. Unfortunately, I looked into the mirror—a serious mistake, because I realized I would have to shave to join the living. My hand was shaky, and, as usual, I cut myself a couple of times, not badly, but enough so that the blood kept running despite tissue, cold water, and a heavy, stinging application of styptic pencil.
I hurried over to the ward. It had stopped raining, although clouds still hung thick and heavy over the hills. My abscess patient was probably a bit startled when I ran into the room and asked him to hold up his hands and spread his fingers. As he did so, I tried to compress all the fingers together and got good resistance; that indicated his ulnar nerve was all right. I didn't have time to see anybody else except my waterlogged edema patient, whose bed was right next to that of the abscess. He had a question about his diuretic pills that I couldn't ignore.
I had developed a great respect for serious edema cases of the sort that requires a lessening of body fluids by one kind of diuretic or another. My awakening had been sudden and brutal—a carcinoma patient, transferred from a medical ward, who had swelled up through total body edema, a condition called anasarca. I decided that she was in that state because the medical department had missed the boat; there was always a little friction between those who cut—the surgeons—and those who treated with drugs—the medicine guys. This patient had cancer, diagnosed from a lymph-node biopsy. Although the primary site had never been found or the exact type of cancer determined, somebody decided to zap her with radiotherapy, which did nothing to the cancer, and then with chemotherapy, which was equally useless. Meanwhile, the patient was on IV's, and the medical boys allowed her to gather so much water that her sodium and chloride levels dropped to the point where she was practically delirious. And they ignored her plasma proteins, which dropped as well. When I got the patient, I was determined to get rid of all that water. By giving her some albumin and a diuretic, I achieved some diuresis, and hence a slight improvement in the edema. But I wanted more. When I tried to get some advice, nobody was much interested, including the attending. Since her urine was alkaline, I decided to give her a good dose of ammonium chloride with the diuretic, and this time the results were spectacular. What a diuresis! Water . poured out of her as her urinary output soared. It was terrific, amazing—except that it would not stop, and overnight she dried up like a prune. Bronchopneumonia set in immediately, and she was dead in a day and a half. I had never said anything more to the medical guys about the case, but I was wary now of those diuretic agents. I was being very careful with this man next to the abscess. He was taking only pills.
Actually, I had learned to respect abscesses as well. There had been one patient—not mine, although I had seen him on rounds every day—who was admitted because of spreading cellulitis in his right leg from an abscessed area. When he came to us, most of his calf muscles had already liquefied. We cultured a number of different organisms out of that abscess; they all seemed to be working together against the patient. One day, when the intern handling the case was sick, I had to drain it. The smell was indescribable; once again I resorted to my three-mask ploy to keep from retching. As I attempted to open the abscess cavity, I realized that it went in every direction, as far as the hemostat would reach. An argument had raged off and on during rounds about whether his leg should come off, but advocates of a new method of continuous antibiotic perfusion won out—at least, they won the argument—and dripped gallons of antibiotic into his leg, seeming to stabilize him for a few days. But suddenly, one day while we were looking at him on morning rounds, the man died. We had just walked up to the bed, and another intern had started to say that the patient was "essentially unchanged." Odd, how often that word "essentially" was used on rounds. This man had been in liver failure, heart failure, kidney failure—in fact, total body failure. But just as the intern was mouthing his neutral status report the patient gasped, and it was over. It seemed an act of enormous bad taste. We stood there dumbfounded. No one tried to resuscitate him, because all of us had become used to the hopelessness of his condition. Our insignificant drugs had only supported him precariously for a while, until the bottom fell out, as it had with those Gram-negative sepsis cases in medical school. It was as if he had absolutely no defense against the infection. Thus I came to respect abscesses. In fact, as time went on, I was learning to respect every illness, no matter how innocuous it appeared to be.
Now I was hurrying on to surgery, already late. There was a lot of activity on the medical floor. I passed interns, residents, and doctors standing around beds talking, as they always were—unless they were sitting around talking in the lounge. Most discussions centered on treatment, on which drugs to use. As a point of agreement would near on some medication, one of the participants would bring up a side effect, whereupon a drug would be suggested to counter the side effect, which drug could, in turn, have its own side effect. Which was worse, the question now became, the second side effect or the original condition? Would the second drug make the original symptoms worse than they were before the first drug made them better? On and on it went, around and around, until usually the discussion got so complicated it seemed best to start again, on the next patient. Or that's what the medical wards looked like to me. Talk, talk, talk. At least, in surgery we did something. But the medical guys pointed out, with some truth, that we just cut it out when we couldn't cure it. We countered that cutting it out did, in fact, often cure it. The argument went inconclusively back and forth, always conducted in an entirely friendly, even jovial, style, but its roots sank deep.
Climbing into another clean scrub suit was a compounded deja vu. I was beginning to live in those things. Since no medium sizes were left, I had to wear a large, and the strings of the pants went around me twice. Through the swinging doors into the OR area. While I was putting on my canvas shoes, I glanced at the board to see who was doing the operation. Zap! It was none other than El Almighty Cardiac Surgeon. But what was he doing here? The procedure was listed as "Abdominal abscess, dirty," and obviously El Almighty usually worked in the chest. Strange things had ceased to surprise me, however. As I looked up, he saw me and greeted me by name, being very friendly, but I knew better than to lower my guard. It was just the first move, a condescending act early in the show— especially since he had to shout the
greeting from halfway down the corridor to make sure everyone noted his good cheer and camaraderie.
I remembered wryly one time when a resident and I were assigned to a cardiac case with not one, but two such surgeons. These men, completely alike in manner and hidden behind masks, could be distinguished only by their girth, one being much fatter than the other. That case had begun smoothly enough, with affability and backslapping all around. Suddenly, with no warning whatever, one of the surgeons began to harangue the resident for giving blood to a patient dying of lung cancer. True, the decision was debatable, but not serious enough to warrant such a tirade in front of all assembled. He was just puffing himself up, improving his self-image. So it went throughout the operation, praise and then blame, each overdone, until we reached a kind of frantic crescendo of invective that gradually ebbed away, back into good humor. It had been like a madhouse.
There is something of this in many surgeons—a kind of unpredictable passive-aggressive approach to life. One minute you are a close and valued friend; the next, who knows? It was almost as if they lay waiting in ambush for you to cross some invisible line, and when you did—wham!—you got a fireworks of verbal abuse.
Perhaps this is a natural effect of the system, the final result of too much intensity and repression through too many years of training. I had begun to feel it in myself. If he wants to get ahead, an intern learns to keep his mouth shut. Later, as a resident, he learns the lesson so well that it becomes internalized. Underneath, however, he is angry much of the time. No matter how cleansing it might have been to tell some guy to stuff it, I never did, and neither did anybody else. Being at the bottom of the totem pole, we naturally aspired to rise higher, and that meant playing the game.
In this game, fear was symbiotic with anger. If anything, the fear portion of it was more complicated. As an intern, you were scared most of the time; at least, I was. At first, like any good little humanist, you were afraid to make a mistake, because it might harm a patient, even take his life. About six months along, however, the patient began to recede, becoming less important as your career went forward. You had by then come to believe that no intern was likely to suffer a setback because of official disapproval of his practice of medicine, however sloppy or incompetent. What would not be tolerated was criticism of the system. No matter that you were exhausted, or were learning at a snail's pace, if at all, and being exploited in the meantime. If you wanted a good residency—and I wanted one desperately—you just took it without a murmur. Plenty of hopefuls were lined up to take your place back there in the big leagues. So I held feet and retractors, and took the other shit. And all the time the anger ate at me.
Most of us didn't believe in the devil theory of history, or in an extreme notion of original sin, and so we knew that these older men we hated so much must have once been like us. At first idealistic, then angry, and then resigned, they had finally come to be mean as hell. At last the anger and frustration, held in so long, were gushing out in a gorgeous display of self-indulgence. And at whose expense? Who else? The sins of the fathers and grandfathers were visited on us, the sons of the system. Would it happen to me? I thought it would. Indeed, it had already started, because I had advanced beyond my period of medical-school idealism. I was no longer surprised that there were so few gentlemen among surgeons; in fact, the wonder of it to me was that any doctors at all came out as whole human beings. Apparently, few did. Not among them was El Almighty, whom I was about to face.
He slapped me on the back, wanting to know how every little thing was. It was as if he were going to give me candy or kiss my baby like a corrupt big-city politician gathering votes. Actually, he was gathering ego points. I was so tired I didn't care what he said or did. I kept my head down, scrubbing away, taking one step at a time. I put on the gown, and then the gloves. The scene around me was unreal. The surgeon's voice boomed on about nothing and everything, several decibels above everyone else. The anesthesiologist seemed to have either a special immunity or effective earplugs; oblivious to the surgeon, he went quietly about his business. Even the nurse ignored El Almighty. Whether he asked politely for a clamp or thundered for one, she would hand it to him in the same reserved efficient way and go on adjusting the instruments. I hoped he was listening closely to himself, because he apparently was his only audience.
The case turned out to be a reoperation for inflammation of the little pockets older people sometimes get in the lower colon. This unlucky patient had been operated on for his diverticulitis, as the condition is called, about a month before. Normally, a three-stage operation is recommended, but the first surgeon to operate on the fellow had tried to do it all at once. The result was a large abscess, which we were about to drain, and a fecal fistula, leading through the previous incision down into the colon, that was draining pus and feces.
Mercifully, the procedure was short. I tied a few knots, all unsatisfactory to the surgeon. Otherwise, I remained silent and immobile as he went on about the vicissitudes of his life when he was an intern. "Really tough in those days ... do histories and physicals ... every patient ... through the door ... and besides ... quarter of the salary . .. and you crooks get ..." I hardly heard it. My exhaustion really made me immune, bouncing all his comments off my brain.
At the end I wandered out and changed into my regular clothes. It was almost four. A little afternoon sun had dodged the thick clouds and was sneaking in the window. The rays refracted and sparkled off the raindrops clinging to the window. It made me think of going surfing. But afternoon rounds were still to come; I wasn't free yet.
Descending to one of the private surgical wards, I saw my gall-bladder patient, who was doing fine. Blood pressure, pulse, urine output—all normal. The IV was going well, and orders were adequate for the night. I wrote in the chart and walked down to the other gall bladder, although I was sure the resident had seen her. And he had.
Stopping by X-ray, I asked a secretary to locate the aortogram taken on my aneurysm that morning, so I could have a quick look. The chief resident had apparently accomplished the job after his mighty struggle. The secretary found the films right away, and I began to put them up on the viewer. There were so many they would not all fit on the screen. Thank goodness the numbers allowed me to get them up in sequence. Now to find the problem— usually an educated guess for me. But this time even I could make out a sizable bulge in the aorta, just beyond the left subclavian artery. Catching sight of me in front of the X rays, the radiologist called me over to give me the usual pitch on portable films, with special reference to the hernia man of the night before. But this time I got the last word. The radiologist was subdued to learn that the patient had died. Perhaps he believed now that I couldn't have sent him up for a regular shot. I relished the victory, although of course I didn't think the X ray, good or bad, could have made any difference.
Everybody on ward service was under control. Both hernias were in good condition, already walking; the gastrectomy had taken a full meal; the veins were ready to go home in the morning; one of the hemorrhoids had had a bowel movement. My abscess patient, not unreasonably, wanted to know why I had squeezed his fingers, and the edema man asked again about his pills, wondering how they made him lose water. I humored both patients with overly simplistic answers.
Only one problem—a new patient, or, rather, a new-old patient, for me to work up. This man, a big decubitus ulcer, had a history of at least twenty-five previous admissions. One was for swallowing razor blades, others for attempted suicide by more traditional methods and for psychoneurohc-conversion reactions, convulsions, alcoholism, abdominal pain, gastric ulcer, appendicitis, liver incompetence—his chart was a checklist of primary and secondary diseases. He had also been in and out of the state mental hospital for ten years. Just the sort of patient I needed, in my freshness and good humor. Talking with him was impossible, because he was so intoxicated he could remember only wild, sketchy details about the previous few hours. Trying to examine him and go through the charts took ove
r an hour. Then I had to clean out his ulcer, a process known by the romantic-sounding French word debridement.
Bent over his buttocks and staring into the black and oozing necrotic ulcer that he had contracted from lying in the same position too long, I wished I had studied law. With a law degree, I would already have been out earning a living for two years. A full wardrobe, an impressive office, crisp, clean papers, a secretary, long, full nights of sleep—all would have been mine. Not one of them was mine now. Instead, I was crouching over an alcoholic's smelly posterior snipping out dead tissue, trying to avoid the stench and discourage nausea. It had been exciting the first time in medical school, putting on that white coat and pretending I was a part of the seething, mysterious hospital complex. And how I'd envied the senior students and interns, with their stethoscopes and little black books and purposeful, knowledgeable ways. I had made it, slowly climbing the ladder of medicine and jumping the specific hurdles—until reality yawned before my eyes. Those buttocks were reality, the rear end of life, where I lived.
As I cut, the ulcer started to bleed a little at the edges. When the patient's knuckles turned white where he was gripping the sheets, and when he started to swear and pound the pillow, I decided that I had reached viable tissue. I squirted in some Elase, which was supposed to continue cleaning the wound by enzymatically breaking down the dead tissue; then I packed it with iodoform gauze. That iodoform gauze was not Chanel No. 5, but at least it dominated the other smells, changing them from sickly dirty to unpleasantly chemical. I preferred the chemical smell. The Elase? I didn't know whether it would work, but I put it in because of an article I'd read recently; it made me feel I was doing something scientific.