I saw the inferior vena cava distend, like a garden hose filling with water. “Now,” I said.
“The tube serves as a stent for the inferior vena cava,” Deepak said, leaning over to look from below. “It's also a crude bypass so blood from the trunk can return to the heart while we make the repair. Now … let's see if we can fix this.”
He adjusted the overhead lights. When I lifted the liver, the bleeding was much less than before, and what's more, the torn edges of the vein were visible on the backdrop of the tube. Deepak grabbed one edge of the tear with long forceps and passed the curved needle through and then grabbed the other edge, passed the needle through that and out, and tied a knot. I let the liver back down. It was a laborious process: lift, grab, pass needle, mop, pass needle to other side, mop, tie, relax the pull on liver.
At some point, just as were nearing completion, I sensed someone at my shoulder. Deepak glanced up but did not say anything.
“Is that a Shrock shunt, son?” a voice behind me said. It was a male voice, polite enough, conscious that it was a delicate moment to intrude, but with the authority of one who is entitled to ask.
Deepak looked up again, then back to his work. “Yes, sir,” he said.
“How big was the tear?”
Deepak pulled up the liver and adjusted the overhead light so the visitor could see. “It was three-quarters of the way around the cava.” The tube hed pushed down from the heart made a lovely internal splint for the vein, and running across it like a crease was the first part of Deepak's neat repair. It was a beautiful sight, order restored from chaos.
“Very impressive,” the voice said. There was no sarcasm, just genuine admiration. I stepped back so the visitor could have a better look, and when I did, he leaned in. “Very, very nice. Id put some gel foam around the raw area of the liver. Were you planning to leave some drains?”
“Yes, sir.”
“I'm assuming you are the attending physician?” the voice said.
“No, I'm the Chief Resident. My name is Deepak.”
“Where is your attending?”
Deepak met the speaker's eyes, and said nothing.
“I see. Not one to get out bed for this sort of thing. Do you ever see him?”
As if in reply, Ronaldo snorted and turned to his dials, feigning disinterest. The visitor looked to Ronaldo and seemed about to bite his head off, but then remembering this wasn't his theater, he didn't.
“And how many Shrock shunts have you done before, Deepak?”
“This is my sixth.”
“Really? In what period of time.”
“In two years here … Unfortunately we see a lot of trauma.”
“Unfortunate, yes. But fortunate for us. We are not ungrateful … Still, six Shrocks, did you say? Remarkable. How have they done?”
“One died, but a week after the surgery. He was walking, eating. Probably a pulmonary embolus.”
“Did you get an autopsy?”
“Partial. The family allowed us to reopen the belly. The repair to the cava looked good. We took photographs.”
“And the others?”
“Second, third, and fifth are alive and well, six months after the operation. Fourth died on the table before I got this far. I had just opened the heart.”
“Do you count that one?”
“I should. ‘Intention to treat’ … that counts.”
“Good man. You should count it. Most surgeons wouldn't. And your sixth?”
“This is him,” Deepak said.
“Right. Well, that's better than my experience. I've done four. That's over six years. They all died. Two on the table, two so close after surgery that it was as good as dying on the table. They weren't all trauma like this. Two were tears from someone trying to remove an adherent cancerous mass. You ought to write up your experience.”
Deepak cleared his throat. “With all due respect, sir. I have. No one will publish a report from Our Lady—”
“Nonsense. What is your full name?”
“Deepak Jesudass, sir. This is my intern—”
“I tell you what, write up this case and add him to your series, and then let me take a look at your paper. If it's good, I'll see that it gets published. I'll send it to the editor of the American Journal of Surgery. I'll check with you to see how this patient does. Good luck. By the way, my name is—”
“I know who you are, sir. Thank you.”
The visitor must have been walking away when Deepak said, “Sir? … If you were to … never mind.”
“What is it, man? I have a cadaver organ that I should have in the air by now. I just stopped to admire your work.”
“If you were to show us how to harvest the liver … we could start it for you, save you time.”
I tried to turn around to look, but because I was holding a retractor, I couldn't.
“I don't trust anyone else to do it,” the voice said. “That's why I do it myself. My chief residents don't have the skill … Smart boys, but they don't get the volume you have in a place like this.”
“We get the volume. And they are shutting us down.”
“What? I had heard some such rumor. I heard Popsy … True?”
Deepak just nodded.
“This is your fifth year?” the voice said.
“Seventh. Eighth. Tenth. Depends how you count, sir.” He didn't mention his training in England.
He didn't need to, because the visitor said, “I hear a Scotch inflection. Were you in Scotland? Took your FRCS?”
“Yes.”
“Glasgow?”
“Edinburgh. I worked in Fife. All over there,” Deepak said.
There was a profound silence. The man behind me hadn't moved. He seemed to be considering this.
“What will you do if they shut down?”
Deepak dropped his eyes. “I'll just keep working. Probably here. I love surgery …”
After an eternity the voice said, “Deepak Jesudass, with a J?” And then he spelled it out. “Did I get that right? Come see me in Boston, Dr. Jesudass. We'll pay your fare. I'll arrange for you to come up to my dog lab. We'll get you going. If anyone can harvest for me, you probably can. When you come up we'll visit at length. Have to run now. Good work, Deepak.”
We heard the door swing behind him.
We worked in silence. At last, Deepak said, “He heard my name just once … and he was able to repeat it.” Deepak's repair was done. He was closing up now, as carefully and efficiently as he had opened. He asked for gel foam from the scrub nurse. “In all my years here, no one's been able to remember my name when I'm introduced. No one has bothered. They usually see us as types, not as individuals.”
His shoulders were straighter, his eyes bright and glowing. I'd never seen my Chief Resident like this. I was happy for him, and proud.
“Who was that?” I said, at last unable to contain my curiosity.
“Call me old-fashioned,” Deepak said, “but I've always believed that hard work pays off. My version of the Beatitudes. Do the right thing, put up with unfairness, selfishness, stay true to yourself … one day it all works out. Of course, I don't know that people who wronged you suffer or get their just deserts. I don't think it works that way. But I do think one day you get your reward.”
“Did you know him?” I said again.
Deepak sidestepped my question and turned to the circulating nurse.
“Did that particular team come for liver or heart?”
“Liver. Another team took the heart and ran.”
Deepak smiled and turned to me. “Marion, I'm not a hundred percent sure, because of his mask; had I seen his fingers I could have been certain. But I have a pretty good idea. You just met one of the foremost liver surgeons in the world, a pioneer of liver transplants.
“What's his name?”
“Thomas Stone.”
CHAPTER 43
Grand Rounds
IBELIEVE IN BLACK HOLES. I believe that as the universe empties into nothingness, past and fut
ure will smack together in the last swirl around the drain. I believe this is how Thomas Stone materialized in my life. If that's not the explanation, then I must invoke a disinterested God who leaves us to our own devices, neither causing nor preventing tornadoes or pestilence, but a God who will now and then stick his thumb on the spinning wheel so that a father who put a continent between himself and his sons should find himself in the same room as one of them.
As a child Id longed for Thomas Stone or at least the idea of him. So many mornings I waited for him at the gates of Missing. I saw that vigil now as necessary, a prerequisite for my insides to harden and cure just like the willow of a cricket bat must cure to be ready for a lifetime of knocks. That was the lesson at Missing's gates: the world does not owe you and neither does your father.
I hadn't forgotten what Ghosh asked of me. Let's just say I'd set it aside. I didn't feel guilty about not following through; I never had time to seek out Thomas Stone, and moreover, wherever he was, I never felt as if I was in his America. I was on an island, a protectorate, a territory that America claimed only in name. In carrying his textbook with me from Addis to Sudan and Kenya and then to America, I had developed a grudging respect for the author. I told myself that the book was my touchstone to Sister Mary Joseph Praise: I saw her hand in the line drawings and I carried the bookmark with her handwriting in my wallet. I'd discovered Thomas Stone in the text, just as he must have discovered himself in the discipline of making notes in a landscape of disease and poverty overcoming his fatigue to fill exercise books with his observations. I was convinced that it was the accumulation of these journals that he pulled together to form a textbook. In doing so, he made his knowledge incarnate.
But when that writer, the sole living author of my DNA, stood peering over my shoulder, it was flesh that became incarnate, flesh of my flesh, with a scent that I should have recognized as kin and a voice that was my inheritance. When he leaned over the patient's belly to see our handiwork, cocked his skull on the atlas and axis vertebrae just so, tucked his arms to his chest, his scapulae gliding out, making himself small so as not to contaminate our field—those movements were echoes of my own.
Surely Thomas Stone sensed some disturbance in the universe and that is why he appeared in our theater. I confess when I didn't know who he was, I felt nothing: no aura, no tingling, nothing other than pride in the miracle Deepak had performed with PVC tube and the uncommon skill in his hands, a skill that the stranger appreciated. When I learned our visitor was Thomas Stone, I was unprepared. Should my first reaction have been anger? Righteousness? I had missed my chance to react while he was there. But now, for the first time since childhood, I wanted to do more than study his nine-fingered portrait. I wanted to know about the living, breathing surgeon who had stood next to me.
In the days that followed, I looked up Thomas Stone in Index Medicus in our library, pulling down one by one the oversize volumes, beginning with 1954, the year of my birth. I wanted to know about the post– Short Practice Stone; I wanted to see what scholarly contributions he had made after leaving the tropics. Ours was a small library, but Popsy had donated his collection of surgical journals dating back to the fifties. I found most of the papers listed in Index Medicus.
In my notebook I plotted out Thomas Stone's scientific career as reflected in his published work. In America his interest was liver surgery, and his career was interwoven with the history of transplantation, with the audacious idea of taking an organ from Peter to save the life of Paul. The story began well before Stone, of course, with Sir Peter Medawar and Sir Macfarlane Burnet in the 1940s, who showed us how the immune system recognizes “self” from foreign tissues and rejects and destroys the latter. Two months before our birth, Thomas Stone published a letter to the editor of the British Medical Journal describing the extraordinary length and redundancy of the colon of many Ethiopians, which he believed explained why it so readily twisted on itself—a condition called sigmoid volvulus. By 1967, when Christian Barnard in Cape Town's Groote Schuur Hospital re placed Lewis Washkansky's scarred and diseased heart with the heart of young Denise Darvall, killed in a car wreck, my father, now in Boston, had become interested in liver resection. His research question was, how much liver could you cut away and still leave enough behind to sustain life?
The transplant field in America was led by a brilliant surgeon— another Thomas, this one with the last name of Starzl. Working in Colorado, Starzl did the first human liver transplants in ‘63 and ‘64, but neither patient survived. Thomas Stone of Boston, the footnotes will show, also tried and failed in ‘65. Despite increasing public criticism, Starzl didn't give up. He performed the first successful liver transplant in 1967. Soon others, Thomas Stone included, managed the same feat. It was still very high risk, but by publishing their experience with such tricks as bypassing portal blood to the superior vena cava during the long surgery, or using the “University of Wisconsin solution” to better preserve cadaver livers, results were improving. The problem was no longer technical, even though this was the most technically difficult operation anyone could perform, the equivalent of a pianist playing Rachmaninoff's “Rhapsody on a Theme by Paganini,” except that one dare not miss a note or fluff a phrase. The operation lasted ten, sometimes twenty hours. Starzl showed it could be done. The two new hurdles were finding sufficient organs to transplant, and of course the problem of rejection of the transplant by the immune system.
In 1980, the year of my internship, Starzl turned his attention increasingly to rejection, focusing on a promising new drug that Sir Roy Calne's group at Cambridge discovered—cyclosporine.
THOMAS STONE TOOK a different approach; he focused on the problem of the shortage of organs and pursued a solution that most others considered a dead end: removing part of a liver from a living healthy parent and giving that to a child whose liver was failing. At least in dogs, he found the liver grew in size to compensate for its loss, while the transplanted segment of liver sustained the recipient. But splitting the donor's liver introduced complications such as bile leaks and clots in the hepatic artery that feeds the liver. It also put a healthy donor's life in real jeopardy, as the liver, unlike the kidney, is unpaired. Even more promising and immediately useful was Stone's work using animal liver cells, trying to strip the cells of those surface antigens which made humans cells recognize them as foreign, and then grow them in sheets on a membrane and use them as a sort of artificial liver—a dialysis type of solution.
As I read about transplants, I was excited. It was clearly one of the most compelling stories in American medicine.
JUNIOR WAS THE CENTER of attention in our ICU. He was deeply sedated, eyeballs roving under closed lids. The kind of trauma hed been through resulted in “shock” lung, or Da Nang lung (recognized in GIs who were resuscitated on the battlefield, only to develop this strange lung stiffness), along with kidney shutdown. According to B. C. Gan dhi's rules, if you had more than seven tubes in you, you were as good as dead. Junior had nine. But one by one, over the weeks, the tubes came out and he got better. It required meticulous nursing care, and Deepak and me poring over his daily flowcharts, anticipating his needs, and intervening with ongoing problems. J.R., as his family called him, left the ICU for a regular room after forty-three days. A week later, smiling sheepishly, he walked out on his own steam with the ICU and trauma teams lined up on either side of the hospital entrance to cheer. If hed shot someone, the witnesses had all vanished, and the police had lost interest, so J.R. was going home. I think it was the sight of J.R. walking out of the hospital that set me on course as a trauma surgeon. His kind of recovery was by no means a rule in trauma surgery, but it happened often enough, particularly in those who were young and previously healthy, that it made the heroic efforts worthwhile. The mind was fragile, fickle, but the human body was resilient.
AS INTERNS we were allowed to attend one national conference, all expenses paid. I chose a liver transplant conference in May in Boston. I arrived on a lovely spring day.
Boston's downtown fit every notion I had of what colonial America was like, and it felt steeped in history, completely different from my section of the Bronx. I told myself that it was coincidence that the conference was in Boston, walking distance from where Thomas Stone worked. I told myself I wasn't there to meet Thomas Stone, but to hear the keynote speaker, Thomas Starzl. As for Thomas Stone's plenary session—I was undecided about attending.
The morning of the conference I could no longer lie to myself. I skipped the transplant meeting and walked the six blocks to the hospital in which Thomas Stone had worked all these years. After wearing scrubs for almost a year, my suit and tie felt strange, as if I were in fancy dress.
“Send them to Mecca” was an expression we used when we dispatched patients to places that offered what Our Lady of Perpetual Succour could not. It was a common medical expression in hospitals all over America, when sending patients to any of the top referral places in the country—Id even seen it in letters to the editor in the medical journals. Now I was going to Mecca.
“MECCA” CONSISTED OF a spanking-new hospital tower, weirdly shaped and shining as if it were made of platinum. It was the kind of structure architects compete to build. From a patient's perspective, it didn't look welcoming. The tower hid the older brick sections of the hospital, whose architecture felt authentic and aligned with the neighborhood.
“Good morning, sir,” a young man in a purple jacket said to me. I glared at him, thinking he was being sarcastic. Then I realized that he and two others stood there ready to park cars and assist patients into wheelchairs.
The revolving doors led to a glass-walled atrium, the ceiling extending up at least three stories and accommodating a real tree. A grand piano played itself by some mysterious mechanism. Around it were plush leather chairs, lamps. Beyond this was a waterfall trickling gently over a slab of granite. Then a reception desk where a concierge, one of three, looked up, smiling, eager to help. I followed the blue line on the floor to the elevators of Tower A, which took me to the Department of Surgery on the eighteenth floor, just as she said it would, but I made no promise about having a nice day. I found it difficult to believe I was in a hospital.
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