Cutting for Stone

by Abraham Verghese

  “It feels as if this is happening because of me,” Hema said. She blew her nose. “I know that sounds selfish, but to lose Ghosh, then to see Marion like this … You don't understand, it feels as if I have failed them all, that I let this befall Marion.”

  Had she turned, she might have seen Thomas Stone stir, seen him rub his knuckles against his temples, as if trying to erase himself. He spoke, his voice hoarse. “You … you and Ghosh never failed them. I did. I failed all of you.”

  There it was, Hema must have thought; it was both the sorry and the thank-you that was so long overdue, and the funny thing was that at this moment, she didn't care. It no longer mattered. She didn't even look his way.

  SHIVA ENTERED, and if he saw Thomas Stone, he didn't acknowledge his presence. He had eyes only for me, his brother.

  “Where were you?” Hema said. “Did you sleep at all?”

  “In the library upstairs. I took a nap there.” Shiva surveyed me, then he studied the settings on the ventilator, and then the labels on the fluid-containing bags hanging over my bed.

  “There is one thing I didn't ask Vinu,” Hema said to Stone. “How did Marion get hepatitis B?”

  Thomas shook his head as if to say he did not know. But since she wasn't looking his way, he had to speak. “It … was probably during surgery. Nicking himself. It's an occupational hazard for surgeons.”

  “It can also be acquired by sexual intercourse,” Shiva said, addressing Thomas Stone. Thomas Stone stammered assent. Hema glared at Shiva, one hand on her hip. She didn't get a chance to speak, because Shiva had more to say: “Genet was at Marion's house, Ma. She showed up there six weeks ago. She was sick. She stayed for two nights and then disappeared.”

  “Genet … ?” Hema said.

  “There are two people in the waiting room you need to meet. One is an Ethiopian lady, Tsige. She used to live opposite Missing. Ghosh took care of her infant years ago. Marion met her again in Boston. The other is Mr. Holmes—he is Marion's neighbor. They want to speak to you.”

  BY MIDMORNING, Hema knew the whole story. Genet had been ill with TB. But Appleby had his hands on the prison health records and they showed what we had not known before: Genet was also a silent carrier of hepatitis B. She contracted it (or so the prison doctor postulated) from an improperly sterilized needle or a transfusion or a tattoo when she was in the field in Eritrea; she could also have acquired it sexually. Genet had bled readily when we slept together, and I had been generously exposed to her blood and thereby to the virus. The incubation period of hepatitis B fit Shiva's hypothesis: it was six weeks from her visit to my falling ill.

  Hema paced the waiting room, cursing Genet and bemoaning my stupidity in letting Genet get close to me again after everything she had put us through. Had Genet appeared just then, I would have feared for her life.

  WHEN DEEPAK AND VINU made rounds together that afternoon they shared the latest lab results: my kidneys were failing; my liver, normally the source of clotting factors, wasn't producing any. If there were any viable liver cells left, they were showing no signs of recovering. There was not a bit of good news they could convey. They withdrew, Shiva following them. Thomas Stone and Hema stayed, silent around my immobile form. Now it was a watching game, a vigil to the end. There was no hope. The two of them as physicians knew it all too well, but if anything, experience made it even less palatable.

  AT NOON, an ICU nurse paged both Deepak and Vinu to a Stone family conference. They came to find Hema and Shiva seated across from Thomas Stone in the small meeting room.

  Hema, weary, head in her hands and elbows on the table, gazed up at the two young doctors in white coats, her son's peers. “You wanted to see us?” she said impatiently to Vinu and Deepak.

  Deepak looked puzzled. “I didn't call this meeting.” He turned to Vinu, who shook his head.

  “I did,” Shiva said. He had a stack of photocopied papers in front of him. A yellow legal pad was covered with notations in his careful script. Hema noticed an authority to his voice, a sense of action and energy and initiative that no one else seemed capable of displaying in the face of my terrible prognosis. “I called the meeting because I want to talk about a liver transplant.”

  Deepak, who found it difficult to sit face-to-face with Shiva and not feel he was speaking to me, said, “We considered a transplant early on, Shiva. In fact, Dr. Stone and I talked about transferring Marion to Mecc—I mean to Boston General, Dr. Stone's hospital. Dr. Stone's team does more transplants than anyone on the East Coast. But we decided against it for two reasons. First of all, transplants are notoriously unsuccessful when the liver is being destroyed by fulminant hepatitis B. Even if we found a cadaver liver of the right blood group and size and we did the transplant successfully, we would have to use massive doses of steroids and other drugs that suppress the immune system to prevent rejection of the new liver. That would give the hepatitis B virus a field day and the new liver would be destroyed and we would be back to exactly where we are now.”

  “Yes, I know,” Shiva said. “But what if the transplant is a perfect match? Not just the same blood group, but all six HLA antigens and other antigens you don't even measure—what if they all matched? Then no immune-suppressing drugs would be needed? Right? None. No steroids, no cyclosporine, nothing. Would you agree?”

  “Theoretically, yes, but …,” Deepak said.

  “A perfect match is what you would have if you took the liver from me,” Shiva said. “His body would see it as self, not as foreign in any way.”

  The air had been sucked out of the room. No one spoke for a few seconds. Seeing Hema's expression, Shiva quickly explained, “I mean take a part of my liver, Ma. Leaving enough for me and taking out a lobe to give to Marion.”

  “Shiva …” It was on Hema's lips to apologize for Shiva—this clearly was not his field, or hers for that matter. But then she changed her mind. She knew something about his tenacity when it came to medical situations that others thought impossible. “But, Shiva, has that ever been done—transplanting part of a liver?”

  Shiva slid one of the articles over to her. “This is from last year. A review by Deepak Jesudass and Thomas Stone on the prospects for live donor liver transplant. It hasn't been done in humans, Ma, but before you say anything, read page three where I have underlined. They say, ‘Technically, the success in almost one hundred dogs, the ability to sustain life in the recipient and not jeopardize life in the donor, suggests that we are ready to perform this operation on humans. The risks to a healthy donor present a significant ethical obstacle, but we believe the critical shortage of cadaver organs obliges us to move forward. The time has come. Live donor transplant will overcome both the problem of organ shortage and the problem of cadaver livers that are damaged because it has taken too long to get consent and too long to remove the organ and get it to where it needs to be. Live donor liver transplant is the inevitable and necessary next step.’ “

  Shiva wasn't reading, but reciting word for word from memory. It didn't surprise Hema, but it astonishmed the other physicians at the table. Hema felt proud of Shiva. She was reminded how often she took Shiva's eidetic gift for granted. She knew he could draw the page he was reciting from, reproduce it on a blank piece of paper, beginning and ending each line just as it was on the original, down to the punctuation, the page number, and the staple marks and photocopy smudges.

  Shiva, sensing that he had quieted Hema for the moment, addressed Thomas Stone and Deepak, the two surgeons: “May I remind you that the first successful kidney transplant by Joseph Murray involved a dying twin who received a healthy kidney from his identical twin brother?”

  Deepak spoke, because it appeared that Thomas Stone was in a state of shock, “Shiva, we also state in the paper,” Deepak said, “that there are ethical and legal implications—”

  Shiva interrupted. “Yes, I know. But you also say ‘in all likelihood the first donors will be a parent or sibling, because such a donor has a pure motive and takes on the risk
willingly’ “

  Deepak and Thomas Stone looked like defendants whose alibi had just been shot down by a surprise witness. The prosecutor was moving in for the kill.

  But the attack came from another quarter. Hema said, “Thomas, tell me the truth: in the last four days, given that this is your area of interest”—she tapped the paper, her fingers bunched together—”seeing Shiva lie next to his twin, did the thought of this live donor operation not cross your mind?”

  If she expected him to squirm and swallow hard, she was in for a surprise: Stone looked steadily at Hema, and after a beat, he nodded almost imperceptibly. “I thought of the Murray twins, yes. I thought of it. But then thinking of all the hazards … I dismissed it. This is much, much harder than removing a kidney. It's never been done.”

  “ I never thought of it!” Vinu Mehta said quietly. “Madam, I should have thought of it. Shiva, I thank you. In anyone else with acute hepatitis B, a liver transplant would simply feed the virus. But with a perfect match … Of course, Shiva, the issue is really the risk to you.”

  My brother was ready, and he spoke without glancing at his notes, addressing his comments largely to Thomas Stone even though Vinu had asked the question. “Your estimate, Dr. Stone, based on cutting out one or more lobes from patients with liver trauma, is that the risk of death should be less than five percent for me, the donor. The risk of serious complications, such as bile leaks and hemorrhage, you said should be no more than twenty percent in an otherwise healthy donor.” Shiva pushed a single sheet to Deepak and Thomas Stone. “I had my blood drawn last night. All my liver functions came back normal. As you can see, I am not a carrier of hepatitis B or anything like that. I don't drink or take drugs that might damage the liver. I never have.” Shiva waited for Thomas Stone.

  “You know that paper of ours better than I do, son,” Stone said. “Unfortunately, those were estimates, a pure guess.” He put his hands on the table. “We don't know how it might really work in humans.”

  “And if we fail,” Deepak added gently, since Thomas Stone was finished, “we lose you who walked in here healthy and we lose Marion. Not to mention that we won't have a leg to stand on or that our careers could be over. Even if we succeed, we will be heavily criticized.”

  If they thought Shiva was done, they didn't know my brother. Hema was seeing her son anew. “I understand your reluctance. I wouldn't think much of you as surgeons if you agreed at once. However, if you can do this operation and if it has a reasonable chance, even a ten percent chance of saving Marion's life, and a less than ten percent chance of ending my life, and if you choose not to do the operation, then in my opinion, you would have failed Marion, failed Hema and me, failed medical science, failed yourselves. You would have failed my brother not only as his physicians, but as his friend, and as his father. If you did the operation and succeeded, you would not only save my brother, but you would have advanced surgery by a decade. The time is now.” He looked his father and then Deepak in the eye. “You may never get a chance like this again. If your rivals at Pittsburgh were facing this situation, what would they do? Would they not be bold?”

  The prosecution rested. It was time for the other side of the table to respond.

  “Bold, yes,” Stone said, breaking the long silence, and speaking in an undertone as if only for himself, “but they wouldn't be operating on their own sons. I'm sorry, Shiva, I can't imagine this.” He pushed back from the table, put his hands on the arms of his chair as if he were thinking of leaving.

  “Thomas Stone!” Hema's voice was sharp as a Bard-Parker blade and it nailed him in his seat. “Once before I asked you for something, Thomas,” she said. “It had to do with these boys. You walked away then. But this time if you walk away, neither I nor Ghosh can help these boys.” Stone turned pale. He sat back in the chair. Hema's voice broke. “Thomas, do you think I would want to subject Shiva to a risk he couldn't surmount? Do you think I want to lose my sons?”

  When she had composed herself, and after blowing noisily on her kerchief, she said, “Thomas, please dismiss from your head the idea that they are your sons. This is a surgical problem and you are in the best position to help them, precisely because they were never your sons. They never held you back, they never slowed your research, your career.” There was no rancor in her voice. “Dr. Stone, these are my sons. They are a gift given to me. The pain, the heartbreak, if there is to be heartbreak, are all mine—that comes with the gift. I am their mother. Please hear what I say. This has nothing to do with your sons. Make your decision by deciding what you must do for your patient.”

  After an eternity, Deepak dragged the yellow pad from Shiva's side of the table and turned to a fresh page. He uncapped his pen and said to Shiva, “Tell me, why are you willing to subject yourself to such a risk?”

  Shiva, for once, did not have a ready reply. He closed his eyes and made a steeple of his fingers, as if to shut out their faces. It worried Hema to see him this way. When he opened his eyes, he seemed for the first time since his arrival to be sad. He said, “Marion always thought that I never looked back. He saw me as always acting only for myself. He was right. He would be surprised if I were to risk my life to donate part of my liver. It isn't rational. But … seeing that my brother might die, I have looked back. I have regrets.

  “If I was dying, if there was a chance he could save me, Marion would have pushed you to operate. That was his way. I never understood it before because it's irrational. But I understand it now.” He glanced at Hema, then shouldered on.

  “I had no reason to think about all this till I got here. But at his bedside … I realized if something happens to him, it happens to me, too. If I love myself, I love him, for we are one. That makes it a risk worth taking for me—it wouldn't be for anyone else, unless they loved him. I am the only one who is a perfect match. I want to do this. I couldn't live with myself if I didn't do this, and I think you wouldn't be able to live with yourselves if you didn't try. This is my destiny. My privilege. And yours.”

  Hema, composed till then, pulled Shiva to her and kissed him on the forehead.

  Deepak, pen poised, had yet to write a word. He put the pen down.

  At that moment it sunk in that they were going to go ahead with what had never been done before.

  Shiva said to Deepak, “You said there was a second reason you had initially dismissed the idea of a transplant. What was it?”

  Deepak said, “Before he lost consciousness, Marion made me promise not to transfer him. This hospital was special to him. It was more than a place for us foreign medical graduates to train. It welcomed us when other places did not. This is our home.”

  Hema sighed and dropped her head into her hands. Just when they had come this far, another obstacle.

  “We can do it here,” Thomas Stone said softly. He had listened to Shiva without moving a muscle, and those blue and steady eyes were now shiny and bright. He pushed his chair back and stood up, his movements purposeful. “Surgery is surgery is surgery. We can do it here as well as anywhere if we have the tools and the people. Fortunately, the world's expert in splitting the liver is sitting right next to me,” he said, putting a hand on Deepak's shoulder, “and the tools, many of which he designed, are also here and will need to be sterilized at once. We have a lot to get ready. Hema, at any time if you or Shiva have a change of heart, all you need to do is say so. Shiva, please don't eat or drink anything from this moment on.”

  As he walked past Shiva's chair, he clamped his hand on my brother's shoulder, squeezed hard, and then he was gone.

  CHAPTER 52

  A Pair of Unpaired Organs

  AHELICOPTER FROM BOSTON GENERAL landed on Our Lady of Perpetual Succour's helipad during the night. It brought special instruments and the key personnel from Boston General's well-oiled liver transplant program. The corridor outside Our Lady's operating suites, normally a desolate stretch where one might find an empty stretcher or a portable X-ray machine parked while the tech took a cigarette break,
was now like battalion headquarters at the start of a military campaign. Two large blackboards had been set up, one labeled DONOR and the other RECIPIENT, each listing what had to be accomplished with a check box next to the task. Our Lady of Perpetual Succour's team with Deepak as lead surgeon would handle the donor (Shiva's) operation, and the Boston General crew with Thomas Stone as lead surgeon would staff the recipient (my) surgery. The Our Lady team wore blue scrubs, while the Boston General crew wore white, and just to be certain, the former had a big D (for “donor”) marked on their hats and scrub shirts with a black marker, whereas the latter had an R. The adrenaline flow kept these disparate teams in good spirits; one Bronx wag even suggested to his Dorchester counterpart that they could call the teams Crackers and Homeboys. Only Thomas Stone and Deepak Jesudass would be common to both teams, each man assisting the other.

  A dry run at midnight with dummy patients in both operating rooms had uncovered a few critical glitches: anesthesia from Boston General needed a better orientation to the setup at Our Lady, and there was need to anoint a “ringmaster” whose job was to be timekeeper, to keep abreast of the activities of both teams, and who was the only person authorized to carry and, most important, record all messages from Team R to Team D and vice versa. Two new blackboards were brought in to be placed inside each theater, and tasks to be ticked off written on these. Our Lady of Perpetual Succour was put on diversion, with trauma being rerouted to other hospitals in neighboring boroughs. By 4:00 a.m. it was time for the real thing.

  Thomas Stone threw up in the surgeons’ locker room. The Our Lady crew saw this as a bad omen, but the Boston General crew assured their counterparts that a pale, diaphoretic Stone augured a good outcome (though in truth, they had never seen him quite so pale and weak, lying prostrate on the bench, a puke basin at his side).