He showered, dressed in a fresh set of scrubs, and paid his customary early-morning visit to the ER lounge for coffee, OJ, and a doughnut with the soon-departing night-shift crew. He was surprised to find Gordo there, powdered sugar still flecked in his beard like Christmas snow. He was regaling the nurses with one of his trademark jokes—the one dealing with lan MacGregor, seated at his usual spot at the bar, deeply and morosely in his cups and, of course, speaking in the heaviest of brogues.
“‘. . . See that pier out there,’ MacGregor says, ‘I built that pier. So, do they call me MacGregor-the-Pier-Builder? Noooo! And that shed over there. I built that, too. Do they call me MacGregor-the-Shed-Builder? Noooo! And . . . and that stone wall out there? I set every single one of them stones in place myself. So am I known as MacGregor-the-Stone-Setter? Noooo! But fuck one lousy goat . . .’ ”
Will joined in the laughter. Even though he had heard the joke enough to qualify as an expert on it, Cameron’s delivery was hilarious enough to make it fresh every time.
“Gordo, what are you doing here at this ungodly hour?”
“Kristin’s snoring woke me up. She swears it was me waking us both up, in addition to the neighbors and a bunch of them in the cemetery down the street, but I know better. Since the powers that be are about to put me on probation for not getting my discharge summaries dictated, and since I’m going to be spending twenty or thirty hours assisting you with that Whipple, I thought I would come on in and get caught up.”
“Kristin’s like a hundred and fifteen pounds,” Will told the crew. “Somehow, I can’t imagine her snoring any louder than a sparrow if she ever even snores at all. My money’s on the Scotsman here. Did you guys save me my jelly stick?”
“We practically had to pry it out of Dr. Cameron’s hands with a crowbar,” a nurse said, “but there it is.”
“Hey, Gordo, you know jelly stick’s my lucky doughnut. I can’t start a big case like this Whipple without having had one.”
“Mea culpa,” Cameron said, “but excuse me for pointing out that it’s the poor slob you’re operating on that needs the luck.”
“Good point.”
Will knew he wasn’t kidding himself about the jelly stick. For as long as he could remember, he had been a creature of lucky maneuvers and talismans, of lucky shirts and rituals. Although his superstitions didn’t run so deep as to paralyze him or even alter his life very much, he did cling to certain routines and clothing when playing poker with his friends in their monthly game or when preparing to do a case in the OR.
After fifteen minutes of small talk, and another Scottish joke, Cameron headed off to the dictation carrels in the record room and Will made his way to the medical library. The Whipple he was about to perform on Kurt Goshtigian was among the most complicated of surgical procedures. Developed in the thirties, the technique was necessitated because the pancreas is anatomically not clearly separated from the GI structures surrounding it—the gallbladder, the duodenum segment of the small intestine, the bile duct, and often the stomach, as well. After the cancerous head of the pancreas and parts of the other organs were removed, the remaining portions would be sutured back to the small intestine to restore continuity and function. Gordo’s sarcastic reference to Will’s painstaking, time-consuming technique in the OR notwithstanding, if things went well, the operation would take four to six hours, and the result would be a cure.
Will had performed or first assisted on fifteen or so Whipples over the years—certainly enough to feel confident about the procedure. Still, the technique and anatomy were complex and variable enough to warrant reviewing them before stepping into the arena. It was crucial before beginning the Whipple to examine the area thoroughly using a laparoscope in order to be as convinced as possible that there was no cancer outside the head of the pancreas. Evidence that the disease had spread to local organs or the inner wall of the abdomen would mean that it was essentially incurable and would strongly if not absolutely mitigate against a procedure as extensive as this one.
After forty minutes of review and actually performing the operation in his mind, Will felt energized and ready. He called the twins to wish them a good day and to review the plans for the rest of their weekend together. Then he made rounds on his three hospitalized patients and finally headed up to the OR suite in the east wing of the second floor.
Thanks to a huge gift from a grateful family’s trust, the surgeons’ dressing room, like the ORs, was state-of-the-art—plushly carpeted with three private showers and a steam room. Following a routine from which he seldom if ever varied, Will left his wallet and watch on the shelf of his locker, laced up his red Converse Chuck Taylors left foot first, pulled disposable shoe covers over them right foot first, tied on a hair cover, then a mask, and finally slipped on the glasses and magnifying loupes he only used in the OR. Next, for five minutes he sat, eyes closed, breathing deeply and slowly, making no real attempt at clearing extraneous thoughts from his mind, but willing himself to relax and thanking God for the opportunity and skill to be a surgeon. By the time he was ready to enter the scrub room, he was experiencing a most pleasant calmness and euphoria. They were sensations he had come to expect, although this one was even more intense than what he was accustomed to.
Kurt Goshtigian was just being wheeled up to the OR when Will entered the scrub room. Gordo, already scrubbed and gowned, was on the other side of the glass OR door, along with a surgical resident who would do the prep and drape on Goshtigian’s abdomen. Will hurried past the scrub sinks and out of the narrow room and caught up with his patient’s stretcher, actually bumping into it, just as it reached the OR. Goshtigian was a solid, weathered fifty-four-year-old with tattoos on his muscular forearms and over his deltoids. His coarse black hair was graying, and his silver stubble suggested he hadn’t shaved for a couple of days. Will pulled his mask down and apologized to the man for bashing into him.
“I’m pretty sure I’ve never done that before,” he said, wondering if maybe he shouldn’t have broken his routine by rushing out of the scrub room.
Goshtigian, dry-mouthed and groggy from the pre-op meds, smiled up weakly and patted Will on the arm.
“You’re just excited about getting to muck around with my innards,” he said.
“We’re going to get that cancer out of you, Kurt, and you’re going to be as good as goo.”
“You mean new.”
“Pardon?”
“You said goo when you mean new.”
Will had no idea what the man was talking about. Probably the pre-op meds, he decided.
“Yes,” he said. “Well, if you’re ready, I’m going to go scrub in. My partner Dr. Cameron is there in waiting for you. I’ll be in soon.”
Will replaced his mask and headed back into the scrub area. The wonderfully pleasant sense of well-being and connection to his world had, if anything, grown more intense. He was halfway through a four-minute scrub when he realized that he had broken his routine again, this time by taking the hexachlorophene-impregnated brush to his right arm and hand before his left. Strange. No big deal, but strange just the same. When he backed out through the scrub-room door and then into the OR, Kurt Goshtigian’s abdomen was already washed, shaved, prepped with an antiinfective, and covered with sterile drapes. Carrie Patel, the best anesthesiologist on the staff, was in the process of putting him to sleep. With a nurse’s help, Will slipped into a gown, had it tied behind him, then drove his hands one at a time into latex gloves, taking pains to do the left hand first. As usual, Gordo was talking almost nonstop.
“So, lad, are ye all boned up on the Whipple? The man’s first name was Allen, you know. Allen Whipple. Now, there’s a piece of trivia for you. . . .”
Beneath his mask, Will smiled at his partner, even though he realized he wasn’t picking up everything Gordo was rambling on about. It was always good to work with him in the OR. For one thing, he was skilled and quick as a surgeon and intuitive as an assistant, and for another, his demeanor kept the team loose a
nd upbeat, even through the most grueling cases.
The initial laparoscopic evaluation went smoothly and showed what Will had prayed it would—no evidence for spread of cancer into the organs adjacent to the pancreas. Throughout the procedure, though, Will sensed a very mild fuzziness to his thinking, and he also noticed that, on and off, especially with fine movements, his hands shook ever so slightly. Low blood sugar? he wondered. He had eaten as usual, so the possibility seemed remote. A virus of some sort? No symptoms to go along with the mild light-headedness. In fact, on the whole, he still felt upbeat and positive.
“Ready, everyone? Well, okay. Number-ten blade, please, Beth.”
“Again, please?” the scrub nurse asked.
Will felt a spark of irritation.
“I called for a ten, a number-ten blade.”
There was more of an edge to his voice than he had intended. The nurse in turn, glaring at him from above her mask, slapped the blade into his palm with more force than usual for her. Across the table from Will, Cameron immediately reacted to the rocky start.
“Okay, Willy,” he said, “a-cutting we shall go.”
The incision Will made, though quite large, was precisely the length he had planned. After bleeders were clamped and cauterized, he sliced open the peritoneal membrane, exposing the structures beneath. So far so good, except that Will was beginning to sense things weren’t good at all. He was feeling nauseated now, and his light-headedness was more constant. For the first time, he wondered if he was going to be able to continue with the operation.
Using large clamps and retractors, he and Cameron pulled the margins of the incision wide apart. The intestines, arrayed just beneath where the peritoneum had been, were moved aside with damp towels, exposing the blood-tinged structures of the operative field, glistening under the harsh saucer lights overhead.
Will’s mouth now felt desert dry. He peered down at the organs—pancreas, stomach, liver, gallbladder—and at the arteries, veins, nerves, and ducts servicing each one. In his mind, he had mapped out almost every second of this procedure. Now he couldn’t remember where he was to start.
“Everything okay, there, Willy?” Cameron asked.
Will glanced up at him from over his mask.
“I . . . all of a sudden . . . I’m not feeling so good.”
“You need a basin? . . . Need to step away?”
“Huh?”
“Will, look over at me. Kara, take those glasses off him. Let me see his eyes. . . .”
“I’m . . . okay . . . just . . . need . . . moment to . . .”
Will felt the light-headedness intensify and a profound dizziness set in as well. His knees became rubbery, and his vision began to darken. He tried to speak, but only guttural sounds emerged from beneath his mask. Clutching at the sterile drape, he lurched to one side, then pitched forward heavily, landing facedown in the gaping incision.
CHAPTER 12
The inestimable blackness was pierced by sound—garbled voices captured by Will’s gradually increasing consciousness. Next came the ghastly sensation of choking—a tube the size of a redwood, clogging his throat.
Will tried to move his arms but met immediate resistance at the wrists. From his earliest days as a med student in the hospital, he had watched patients be intubated and put on a ventilator—some comatose, some semiconscious—and wondered what it could possibly have felt like. He had even asked some of them after they were on the way to recovery and had concluded that the degree of helplessness, pain, and horror of the situation was a function purely of how much medication they had received. From time to time, especially with emphysema cases, the relief of being able to get in enough air made the breathing tube tolerable. But mostly, the discomfort was quite frightening, especially in the initial hours, before there was any chance to learn to cope.
Will knew he would never again have to ask a patient about the sensation.
He thrust his tongue against the hard rubber airway that had been slipped into his mouth next to the tube and then taped in place to keep him from biting down. Awareness was rapidly returning, along with swirling memories of becoming sick, terribly sick, in the OR. He must have stopped breathing, or come damn close. The fact that the discomfort and panic seemed manageable suggested he was being medicated. Was this the first time he had been awake? With no little effort, he forced his eyelids apart. Even before his focus sharpened, he knew that he was in the ICU. The fluorescent lights over him were midday bright. Across the cubicle, two nurses were talking.
Was it a stroke, he wondered? Is that what had happened to him? A cerebral hemorrhage of some sort? Methodically, he tested his hands and arms, then his feet and legs. No problem moving anything.
The incision! He had gotten horribly dizzy and toppled over into the incision. He could envision the blood and the coils of intestine as he pitched downward toward them. But there the images stopped.
How long had he been out? What happened to his patient?
He opened his eyes wider. As his consciousness grew, so did the suffocating discomfort in his throat. He also became aware of another unpleasant sensation—the desperate need to pee. Easy, easy, he told himself. There was no way he could have been unconscious on a respirator in the ICU and not have had a catheter inserted to drain his bladder. Easy. The pressure and urgency was almost as dreadful as the tube. He had never been a hospitalized patient before. Now he wondered if he had been sympathetic enough with those who were.
The nurses were two whom he knew well, Anne Hajjar and Donna Lee. He banged the back of his hand against the guardrail.
Donna rushed over, clearly pleased to see him awake. Sharp features and close-cut blond hair, she was a new wife in her late thirties and a hardened veteran of the ICU wars. Like the other unit nurses, she called all but the most unapproachable physicians by their first name.
“Will, hi there, it’s Donna. Welcome to the land of the living.”
Will nodded that he understood.
“Are you in any pain?”
He twisted his hand and pointed toward the tube.
“Ken Millstein is taking care of you. Your blood gases are looking pretty good, so maybe he’ll be able to pull that tube out after all the labs are back. Meanwhile we can keep you medicated.”
Will shook his head. No. No medication. I can handle this . . . just not too long.
“Okay, but you sort of woke up a little while ago and started tearing at the tube. That’s why we medicated you and put those restraints on.”
I understand.
“Go after the tube again like that and we’ll have to beat you with a stick. Do you know what happened to you?”
No.
“Apparently, you had a seizure of some sort while you were doing a case. You immediately lost consciousness, and then a few minutes later you stopped breathing altogether. You were rushed down to the ER, and they put the tube in there. Your EKG is normal, so it doesn’t look like a coronary, and your chest X-ray doesn’t show any sign of aspiration. Is there anything you need right now?”
Will wriggled the fingers on both hands and pointed back at the restraints.
“Anne?”
Anne Hajjar, willowy, brown-eyed, and eternally lighthearted, materialized at the opposite side of the bed from Donna and squeezed Will’s hand. Of all the nurses in the hospital, she was his favorite.
“Hey, big boy, we’re glad you’re coming around,” she said. “We were a little worried when they dragged you in here.”
“He wants the restraints off,” Donna said. “I told him if he pulled that tube out it would not go well for him.”
“I suspect it would be the last thing that shape he ever pulled,” Anne said, undoing the Velcro cuff and strap on her side.
As soon as the restraints were removed, Will brought his hands together and pretended to be writing on an imaginary pad. Donna left and quickly returned with a stack of progress-note paper on a clipboard and a Bic pen. At that moment, internist Ken Millstein moved in next to
Anne. He was a slight, Harvard-trained doc about Will’s age, but half a foot shorter, with a rapidly receding hairline and a penchant for baggy suits. He and Will and their wives had been friends from their earliest days at Fredrickston General, and the Millsteins had been one of the very few couples who hadn’t found it necessary to side with one or the other of them after the divorce.
“Eventful day,” Millstein said.
I guess, Will wrote. How long have I been here?
“Two hours, give or take. You had us worried for a while there.”
How is my patient?
“Gordon is still in the OR with him. I think he called Jim Katz in to help finish the procedure. Apparently you got a ten from the Russian judge for that dive you took.”
Very funny.
“Any idea what could have happened? Because I sure don’t.”
None. I have never passed out before.
“Will, you didn’t just pass out. You stopped breathing. Your blood pressure was heading south when Steve Edelstein in the ER decided to go ahead and intubate you.”
Good man.
“Any medical history we should know about?”
Asthma as a child.
“Meds?”
None.
“Feel okay now?”
Groggy.
“No surprise there.” Millstein checked Will’s pupils, then examined his heart and lungs. “I’ll tell you what,” he said. “I’ve run so many labs that your HMO is probably going to put a bounty on my head. As soon as I have most of them back, I’ll get anesthesia in here and we’ll pull that tube.”
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