Cutting for Stone

by Abraham Verghese

  “But this was a large ulcer on the greater curvature?”

  “Yes.”

  “And which ulcers in the stomach are more likely to be malignant?”

  “Those on the greater curvature.”

  “So your suspicion for malignancy was high, right? Did you look at the slides with the pathologist?”

  “No, sir,” I said, dropping my eyes.

  “I see. You trusted the pathologist to read the biopsies for you?”

  I said nothing.

  Deepak's voice wasn't raised. He could have been talking about the weather. Dr. Ronaldo couldn't hear him.

  Deepak explored the pelvis, swept with his fingers to those places we could not see. Finally he said, almost under his breath, “Marion, when it's your patient and you are basing your surgery on a biopsy, be sure to look at the slides with the pathologist. Particularly if the result isn't what you expect. Don't go by the report.”

  I felt terrible for Mr. Walters. I could have spared him this operation, spared him Popsy In retrospect, Mr. Walters s liver function tests were marginally off, and that should have been a clue.

  Deepak repaired the hole in the bowel. Fortunately, there was just one. He oversewed the bleeding ulcer in the stomach; it would in time bleed again. We washed out the abdominal cavity with several liters of saline, pouring it in, then suctioning it out.

  “Okay, come to this side, Marion. I want you to close.”

  I worked steadily under his eagle eye.

  “Stop,” Deepak said. He cut away the knot I had tied. “I know you have probably done a lot of surgery in Africa. But practice doesn't make perfect if you repeat a bad practice. Let me ask you something, Marion … Do you want to be a good surgeon?”

  I nodded.

  “The answer isn't an automatic yes. Ask Sister Ruth. In my time here, I've asked that question of a few others.” I could feel my ears turning red. “They say yes, but some should have said no. They didn't know themselves. You see, you can be a bad surgeon, and as a rule you will make more money. Marion, I must ask you again, do you really want to be a good surgeon?”

  I looked up.

  “I guess I should ask what does it involve?”

  “Good. You should ask. To be a good surgeon, you need to commit to being a good surgeon. It's as simple as that. You need to be meticulous in the small things, not just in the operating room, but outside. A good surgeon would want to redo this knot. You're going to tie thousands of knots in your lifetime. If you tie each one as well as humanly possible, you'll experience fewer complications. I want to see even tension on both limbs. The last thing you want is for Mr. Walters to have a burst abdomen when he gets post-op bloating. That knot, done well, may allow him to go home and get things in order. Done poorly it could keep him in hospital with one complication after another till he dies. The big things in surgery depend on the little things.”

  That afternoon we sat in the cramped office of Dr. Ramuna, the pathologist. She found cancer in the edge of one of the six biopsies I had taken days ago. A stern lady, Dr. Ramuna had a way of pursing her lips that reminded me of Hema. She was unfazed about having missed the cancer the first time. She pointed to the teetering stack of cardboard slide trays by her microscope—biopsies waiting to be read. “I'm doing the work of four pathologists, but I'm only here half-time. Our Lady can't afford more that that. But they don't give me half the work. I can't spend enough time with each specimen. Of course I missed it! No one comes down here to go over slides with me, other than you, Deepak. They call. ‘Have you read this specimen yet? Have you read that specimen?’ If it matters to you, come down, I say. Give me good clinical information and I can do a better job of interpreting what I see.”

  I KEPT VIGIL over Mr. Walters. We had passed a tube through his nose into his stomach and connected it to wall suction, to keep his gut empty for the next few days. He was miserable with the tube and hardly spoke.

  On the third post-op day I took out the nasogastric tube. He sat up, smiled for the first time, taking a deep breath through his nose.

  “That tube is the Devil's own instrument. If you gave me all of Haile Selassie's riches, I'd still say no to that tube.”

  I took my own deep breath. I sat on the edge of his bed. I held his hand. “Mr. Walters, I'm afraid I have some bad news. We found something unexpected in your belly.” This was the first time in America that I had to give someone news of a fatal illness, but it felt like the first time ever. It was as if in Ethiopia, and even in Nairobi, people assumed that all illness—even a trivial or imagined one—was fatal; they expected death. The news to convey in Africa was that you'd kept death at bay. Those things that you couldn't do, and those diseases you couldn't reverse, were left unspoken. It was understood. I don't recall an equivalent word for “prognosis” in Amharic, and I'd never tried to speak to a patient about five-year survival or anything like that. In America, my initial impression was that death or the possibility of it always seemed to come as a surprise, as if we took it for granted that we were immortal, and that death was just an option.

  Mr. Walters s expression went from joy over the tube being out, to shock, and finally sadness. A single tear trickled down his cheek. My gaze turned foggy. My beeper went off, but I ignored it.

  I don't think you can be a physician and not see yourself reflected in your patient's illness. How would I deal with the kind of news I'd given Mr. Walters?

  After a few minutes, he wiped his face with his sleeve. A smile cracked his features. He patted my hand.

  “Death is the cure of all disease, isn't it? No one is prepared for news like this, no matter what. I'm sixty-five years old. An old man. I have had a good life. I want to meet my Lord and Savior.” A mischievous light flashed in his eye. “But not just yet,” he said, holding up a finger and laughing, a slow metronomic sound, heh-heh-heh …

  I found myself smiling with him.

  “We always want more, heh-heh-heh“ he said. “Ain't that the truth, Dr. Stone? Lord, I'm a-coming. Not just yet. I'll be right there, now. You go on, Lord. I'll catch up with you.”

  I admired Mr. Walters. I wanted to learn to be this way, to possess his steady rhythm, to have that inner beat playing quietly inside me.

  “You see, young Dr. Marion, that's what makes us human. We always want more.” He clasped my hand now, as if he was ministering to me, as if Ihad come to sit on his bed for reassurance, courage, and faith. “Now you go on. I know you're busy. Everything's just fine. Just fine. I just got to think this one out.”

  I left him smiling at me, as if I had given him the greatest gift one man could ever give another.

  CHAPTER 40

  Salt and Pepper

  AFTER LEAVING MR. WALTERS'S ROOM, I sat on the park bench by the house staff quarters. How unfair to Mr. Walters that his darkest day should be so impossibly beautiful. The trees of Our Lady turned colors I had never seen in Africa. And then they blessed the ground below with a fiery red, orange, and yellow carpet, which crunched underfoot and released a dry but sweet fragrance.

  The laughter and shrieks coming from inside our building, from the patio, felt sacrilegious. B. C. Gandhi had christened our quarters “Our Mistress of Perpetual Fornication.” There were days when I felt I lived in Sodom.

  When it turned chilly, I went inside. I caught a glimpse of the roaring wood fire in the cast-iron pot on the patio, and the scent of tobacco and something more pungent. Nestor, our Carribean fast bowler and my fellow intern, had a herb garden at the back of our building. The summer we arrived he grew a bumper crop of curry leaves, tomatoes, sage—and cannabis.

  Beyond the herb garden the meadow sloped down to a brick fence topped with razor wire. It separated us from a housing project named Friendship by the city authorities twenty years ago. It was now called Battleship by one and all. At night we heard the pop of handguns from Battleship and saw comet streaks, messages from earth to sky.

  On Mondays we gathered at the nurses’ quarters for a communal dinner at their
invitation. But on this day it was their turn to visit us. I joined the crowd.

  “How did it go?” B.C. said, coming over, putting his arm around my shoulders. I told him about my conversation with Mr. Walters.

  B.C. listened quietly, and then said, “What a good man he is! What courage. You know, we've been lucky with Mr. Walters, particularly since he's a zero-to-one dirtballer. What's a dirt ball? The hard, stinky concretion that forms in the belly button. A patient with four dirt balls is often an alcoholic. He's had one or two heart attacks. Beats his wife. He's been shot a couple of times. He has diabetes. Kidney function is borderline. You try a BFO for a Triple A, guess what happens?”

  “BFO” was Big Fucking Operation, and “Triple A” was Abdominal Aortic Aneurysm. B.C. loved acronyms and claimed to have invented a good many of them. A patient near death was CTD—Circling The Drain.

  “A four dirtballer? … I guess he does terribly with a big operation?” I offered.

  “No! Just the opposite. You see, he's already demonstrated his capacity to survive. Heart attacks, strokes, stabbings, falls off buildings—his protoplasm is resilient. Lots of collateral vessels, backup mechanisms. He waltzes out of the recovery room, farts the first night, pees on the floor trying to get to the bathroom, and does great despite the bourbon the family sneaks in to add flavor to the ice chips, which are all he's supposed to eat.

  “The zero-to-one dirtballers are the ones to watch out for. They are your preachers or doctors. Men like Walters. They live good clean lives, stay married to the same woman, raise their kids, go to church on Sundays, watch their blood pressure, don't eat ice cream. You try a BFO for a Triple A and you will be CDSCWP.”

  Canoeing Down Shit Creek Without a Paddle.

  “As soon as the anesthesiologist brings the mask near their face, your zero dirtballer has a heart attack on the goddamn table. If you manage to operate, the kidneys conk out or the wound breaks down. Or they get confused, and before you can call the Freud Squad they've jumped out of the window. So you see, your Mr. Walters was lucky.”

  Deepak took a drag on a cigar-size joint that Nestor passed to him. He handed it to me. “Here,” he said, holding the smoke in, and speaking in a clipped voice. “The point is … clean living will kill you, my friend.”

  The cannabis did nothing for my fatigue. Soon I felt my face and body turn to wax. I stared into the sky above Battleship. The sounds— good-natured yelling, screams, the throb of a boom box, the clang of a basketball rattling the metal rim, the squeal of tires—were a symphony. They matched the chiaroscuro designs on the brick wall. I felt I could see into Battleship and that I was watching the lives of the hundreds of Americans living there, families who got their medical care from us. I felt like a visionary.

  “Doesn't it seem strange,” I said, after a long while, struggling to frame my question so it wouldn't sound silly, “doesn't it seem strange that … here we all are, foreign doctors—”

  “You mean Indian doctors,” Gandhi said. “You're half Indian, but luckily for you it's the pretty half. Even Nestor here has an Indian father, he just doesn't know it.”

  Nestor threw a bottle cap at Gandhi.

  “Yes, well, doesn't it seem strange,” I went on, “that here we are, a hospital full of Indian doctors and on the other side of that wall are the patients we are taking care of. American patients, but not representative of—”

  “You mean black patients, mon,” Nestor said in his lilting accent. “And you mean Puerto Ricans.”

  “Yes … but what I am getting at is where are the other American patients? Where are the other American doctors for that matter?”

  “You mean where are the white patients? Where are the white doctors, mon?”

  “Yes!” I said. “Precisely!”

  “Look here, Marion,” Gandhi said. “You mean to say you hadn't noticed this fact till just this moment?”

  “No … I mean, yes, I have. Don't be silly. But my question is, are all hospitals in America like this?”

  “My goodness, Marion, you do understand why you are here and not at the Mass General?”

  “Because … I didn't apply there.”

  I was unprepared for the laughter that greeted me. Just when I thought I was on to something profound.

  Nestor got up and jogged in place. He chanted, “Heenot not apply there! Heenot not apply there!” The cannabis seemed to facilitate their hysterical giggles, but it was doing nothing for me. I was getting angry. I rose to leave.

  Gandhi grabbed my arm. “Marion, sit down. Wait. Of course you didn't apply,” he said soothingly. “You didn't want to waste your time on the Massachusetts General Hospital.”

  I still didn't get it.

  “See here,” he said, taking a saltshaker and pepper shaker and putting them side by side. “This pepper shaker is our kind of hospital. Call it a—”

  “Call it a shit hole, mon,” said Nestor.

  “No, no. Let's call it an Ellis Island hospital. Such hospitals are always in places where the poor live. The neighborhood is dangerous. Typically such hospitals are not part of a medical school. Got it? Now take this saltshaker. That is a Mayflower hospital, a flagship hospital, the teaching hospital for a big medical school. All the medical students and interns are in super white coats with badges that say SUPER MAYFLOWER DOCTOR. Even if they take care of the poor, it's honorable, like being in the Peace Corps, you know? Every American medical student dreams of an internship in a Mayflower hospital. Their worst nightmare is coming to an Ellis Island hospital. Here's the problem—who is going to work in hospitals like ours when there is a bad neighborhood, no medical school, no prestige? No matter how much the hospital or even the government is willing to pay, they won't find full-time doctors to work here.

  “So Medicare decided to pay hospitals like ours for internship and residency training programs, get it? It's a win-win, as they say—the hospital gets patients cared for by interns and residents around the clock, people like us who live on site, and whose stipend is a bloody fraction of what the hospital would pay full-time physicians. And Medicare delivers health care to the poor.

  “But when Medicare came up with this scheme, it created a new problem. Where do you get your interns to fill all these new positions? There are many more internship positions available than there are gradua ting American medical students. American students have their pick, and let me tell you, they don't want to come and be interns here. Not when they can go to a Mayflower hospital. So every year, Our Lady and all the Ellis Island hospitals look for foreign interns. You are one of hundreds who came as part of this annual migration that keeps hospitals like ours going.”

  B.C. sat back in his chair. “Whatever America needs, the world will supply. Cocaine? Colombia steps to the plate. Shortage of farmworkers, corn detasselers? Thank God for Mexico. Baseball players? Viva Dom i n ica. Need more interns? India, Philippines zindabad!”

  I felt stupid for not having seen this before. “So the hospitals where I was going to interview,” I said. “In Coney Island, Queens—”

  “All Ellis Island hospitals. Just like us. Allthe house staff are foreigners and so are many of the attending physicians. Some are all Indian. Some have more of a Persian flavor. Others are all Pakistani or all Fili pino. That's the power of word of mouth. You bring your cousin who brings his classmate and so on. And when we finish training here, where do we go, Marion?”

  I shook my head. I didn't know.

  “Anywhere. That's the answer. We go to the small towns that need us. Like Toejam, Texas, or Armpit, Alaska. The kinds of places American doctors won't go and practice.”

  “Why not?”

  “Because, salah, in those villages there's no symphony! No culture! No pro-ball team! How is an American doctor supposed to live there?”

  “Is that where you will go, B.C.? To a small town?” I said.

  “Are you kidding? You expect me to live without a symphony? Without the Mets or the Yankees? No, sir. Gandhi is staying in New York.
I am Bombay born and Bombay bred, and what is New York but Mumbai Lite? I'll have my office on Park Avenue. You see, there is a crisis in health care on Park Avenue. The citizens are suffering because their breasts are too small or their nose is too big, or they have a roll around the belly. Who will be there for them?”

  “You will?”

  “Fucking right, boys and girls. Hold on, ladies, hold on! Gandhi is coming. B.C. will make it smaller, bigger, softer, cuter, whatever you want, but always better.”

  He held his beer aloft. “A toast! Ladies and gentlemen. May no Ameri can venture out of this world without a foreign physician at his or her side, just as I am sure there are none who venture in.”

  CHAPTER 41

  One Knot at a Time

  ONE AFTERNOON, in my ninth month at Our Lady of Perpetual Succour, as we were on our way to the operating room, a bailiff served Deepak Jesudass with papers. My Chief Resident took them without comment, and we went on with our work. Well after midnight, as we sat in the locker room outside the theater and smoked, he smiled at me and said, “Anyone else would have asked me what the papers were about.”

  “You'll tell me if it concerns me,” I said.

  Deepak was perhaps thirty-seven when I met him. He had a youthful face and boyish shoulders that belied the bags under his eyes and the gray streaks in his hair. Had you seen us all in the cafeteria, you would have guessed B. C. Gandhi was the Chief Resident, because B.C. looked the part. But when I reflect back on my surgical training, I'm indebted to a small, dark man, a self-effacing surgeon whom the world might never celebrate. In the operating room, Deepak was patient, forceful, brilliant, creative, painstaking, and decisive—a true artisan.

  “Don't stutter with that needle holder.” “Self-discipline with those hands, Marion. Do each step just once, no wasted motion.” When I learned to cross my hands the way he suggested to get equal tension on both limbs of the knot, a new problem arose: “Keep your elbows in, unless you're trying to fly.” I redid more knots than I tied when I was with him. I took down entire suture lines and started again till he was satisfied. I gave new thought to light and exposure. “Working in the dark is for moles. We are surgeons.” His advice was sometimes counter intuitive: “When you are driving, you look to see where you are going, but when you are making an incision, you look to see where you have been.”