Hundreds of Interlaced Fingers

by Vanessa Grubbs, M. D.

  A hollowed-out needle connected to plastic tubing punched through the first incision and my belly was filled with air. A trocar, something that looked like one of those jumbo pencils for preschoolers, but hollowed out and with what looked like a spinning top, replaced the needle. A camera was passed through it. It magnified my insides almost fifteen times and displayed them on a twenty-one-inch monitor.

  Three more trocars were pushed through. One through each cut. Through each trocar the instruments were passed. Little grabbers and scissors at the ends of long metal rods. The surgeons’ wait for each instrument was on the order of milliseconds as the scrub tech anticipated their every move. They watched the monitor as they moved the instruments like puppeteers manipulating my organs and the stuff between them.

  It was all shades of pink with some areas of iridescence reflecting the camera’s light. All of it looked like one vague indistinguishable mess to the average person. But Frank and his assistant worked as if everything was labeled like in the medical school anatomy books. They worked steadily, identifying my structures almost in whispers as they singed through planes of tissue. Spleen and large bowel were moved aside to bring my left kidney into view. They traced its ureter still working to carry newly generated pee to my bladder. They slung a plastic loop around it so it could be quickly found later. Back up to the kidney’s vein and artery. Plastic loops were slung around them too after all the extra was cleared, including two veins sprouting off the kidney’s vein. Robert wouldn’t need my gonadal and lumbar veins, so they were clamped and cut. All fluff removed.

  Other than the beep, beep, beep, sounding throughout each singe, the room was quiet. Words were spoken only as needed. Including names. Everyone simply knew when he or she was being spoken to. All fluff removed.

  “Look the camera back up to the spleen,” Frank instructed the fellow.

  With his left hand, the fellow directed the camera as told.

  “Take that down there. . . . No, like this.”

  The fellow corrected himself as he etched each lesson into his brain.

  “How much urine?” Frank asked, his voice a little louder.

  “Ten cc’s in the last fifteen minutes,” reported the nurse without hesitation, as if she were anticipating the question.

  “Is the Mannitol in?”

  “Another twelve point five milligrams going in now,” from the anesthesiologist.

  “Follow that with another twenty of Lasix.”

  “Yes. Twenty milligrams of Lasix going in now.”

  “Let them know time to kidney out is fifteen minutes.”

  The nurse left the room to carry out the order.

  More clearing, isolating the kidney. Another cut over the one made to pull Avery out five years earlier. My belly deflated. Tiny bleeding capillaries peeking out from my belly fat singed along the way. Then a stillness as they waited for Robert’s surgeon, Shun Kobayashi, to enter the room.

  I remember meeting Kobayashi from the transplant coordinator’s office the week before surgery. He shook Robert’s hand and then mine. I noticed the short, stubby fingers that didn’t reach past my palm. They matched his short, stubby frame, but not the image I had in my mind of what a surgeon’s fingers would be like—long and almost elegant like a pianist’s. He seemed pleasant enough, so Robert liked him, because it was a good thing to like one’s surgeon, he thought. But we both thought how odd he looked in his green surgical scrubs topped with a tweed jacket instead of a white lab coat. He looked like he was trying to present an unnecessary formality but that he really didn’t want to fully commit to it by getting fully dressed. It made me not trust him, but Robert dismissed it as just a manifestation of the typical nerdiness all doctors shared to some degree or another.

  Now Kobayashi was donned in sterile gown, sterile gloves, surgical cap, mask, and a headpiece fitted with little spotlights and magnifying lenses. Close to his chest he held a flat-bottomed bowl filled with a clear icy slush in his hands like it was a blanket waiting to catch a newborn baby. He stood opposite Frank and the fellow.

  As he walked in, a new sense of urgency overcame the room. There were no words. Just movement. Snip, snip, snip, in rapid succession, and my kidney was freed. Now the passing seconds were counting the time my kidney had no blood flow. With each passing second, more bits of my kidney were at risk of suffocating. Dying. No longer working. Metal rods out, out, out. One last look at my kidney with the camera. Then a sudden thrust of Frank’s gloved hand, then forearm, then almost elbow, through my C-section, soon-to-be nephrectomy, scar as my belly deflated, taking the camera’s ability to project the visual field with it. Frank’s eyes were fixed, concentrated but not seeing straight ahead. Reaching. Finding. Grasping. Pulling. He was determined to grasp my slippery kidney before it had a chance to drop down into my right side, at which point he knew finding it would be like finding a peanut in a box of worms—a four-inch kidney in twenty feet of small intestines. But he had it. He exhaled slightly, relieved.

  Out came my kidney, fully contained in the palm of his hand. It was smooth, dark pink, and shiny with bits of extraneous tissue hanging from its artery, vein, and ureter.

  Toss!

  Into the icy bath in Kobayashi’s arms it was submerged. It was Robert’s kidney now. And with a near-military precise left-face turn, Kobayashi was on his way out of the room back to Operating Room 18 next door, where with his fellow less than two minutes earlier he had been clearing a space in Robert’s pelvis for my old kidney and his new kidney to lie.

  With the excitement over, attention turned back to me like stunned restaurant patrons returning to their meals after a fighting couple stormed out. The fellow methodically sewed my C-section/nephrectomy incision closed, then filled my belly with air so that the camera could once more show them that all the clips were holding and there was no more oozing in need of cautery. Camera out. Air out. Final stitches to close the tiny incisions. And after all this I’d lost less than 4 tablespoons of blood.

  Vanessa. Vanessa. Suddenly I heard a woman’s voice piercing into my consciousness. Pleasant. Singsongy. It must belong to the person who was nudging me.

  “You’re all done,” she said.

  I opened my eyes and looked at her, surprised to see this new face when it seemed I had just blinked at the elevator a moment ago.

  “You’re in the recovery room,” she said brightly.

  It was at that moment—and not until that moment—that I realized the bigness of what I had done.

  I smiled back at the nurse, happy to be awake.

  Part II

  But Will She Stay

  6

  Complications

  I looked to my right and saw Robert in the surgical recovery bay next to mine. He was smiling at me, finally believing a transplant was happening for him. I smiled back.

  I thought of the others who had considered this same path and had maybe even spoken their intentions out loud, but then retreated long before reaching that point of no return. I wondered why retreating hadn’t even occurred to me. Was I that blinded by love? Was I that naive? Was I trying to earn my own forgiveness for past mistakes?

  Yes. Definitely. Maybe.

  But in that moment I felt thankful that retreating hadn’t occurred to me, that I had been so bold, regardless of the reasons why.

  My eyes left his to look for the bag collecting urine from his Foley catheter. I found it hanging by a plastic hook at the foot of the bed. Pale yellow urine—and a lot of it—was there. The kidney was working beautifully. I smiled bigger, with teeth showing, and brought my eyes back to his. He saw the happy in my face and matched my smile. We reached for each other, though we were too far apart to touch fingertips. But it didn’t matter, because in a way we were already touching. We were tethered, connected through our new state of sharing two healthy kidneys between us, replacing his old tether to the dialysis machine. We settled for a fingertip wave.

  “I feel like the fatigue has just lifted off me,” Robert said, amazed.
He didn’t realize how tired he had been. He thought it would be several days before he’d notice a difference.

  I smiled bigger, even though I felt like all of his fatigue had been dropped onto me. This was new to me. The most my healthy body had endured before this day was a C-section to bring Avery into the world.

  Robert, on the other hand, had endured kidney failure and all that came with it. Having a dialysis catheter inserted. The catheter becoming infected. Sepsis, the infection spreading into his bloodstream. The catheter being removed. A new catheter put in. A surgery to create his fistula. Another surgery to revise his fistula when it wasn’t working properly. Nausea. Vomiting. Leg, back, jaw, hand, everywhere cramping. Dialysis Monday. Dialysis Wednesday. Dialysis Friday. For almost six years.

  But now he had a healthy kidney.

  Some hours after surgery, after we had each been moved out of recovery to our separate rooms in the kidney transplant unit, I was happily pushing the patient-controlled analgesia button as often as I was told I could. Then, just before midnight, Robert walked into my room. He was with a nursing assistant and using a walker and wincing a little, but he was up, out of bed, and walking the evening after having an abdominal surgery as I lay in bed pushing the PCA button every few minutes. Wuss, I thought of myself.

  It was like watching a woman in labor refusing all pain medication while I was calling for the anesthesiologist. In truth, I was that woman calling for an anesthesiologist when Avery was born. Avery was in distress—butt first and pooping—so I would have had to have anesthesia to be rushed off to C-section anyway, but after a couple hours of that blinding white pain every few minutes, I was asking for the epidural long before anybody knew of Avery’s distress. I started out wanting to feel the experience of labor in its entirety—dilating cervix, pushing, all of it. I felt my cervix open from three centimeters to four. Good enough, I thought, and exhaled calmly, “Anesthesiologist, please,” when the white before my eyes receded into color again.

  “Hey,” Robert said, smiling brightly in the doorway.

  He padded slowly to me and leaned over to plant a kiss on my lips. He grimaced a bit as he straightened, but still smiled because the pain was because he just got a kidney. Things were good. He could feel how it would be having a normal kidney working all the time rather than the little bit of kidney in the form of a dialysis machine a few hours each week.

  His eyes weren’t red anymore. His skin no longer had that washed-out look. He had already been happily guzzling ice-cold water from the pink plastic hospital pitcher to his heart’s content.

  “They told me to drink,” he said, grinning.

  I grinned back. I was so happy for him. Gone were the days of having to limit how much liquid he took in between dialysis treatments. Now he had a kidney that could pee out any fluid his body didn’t need. He focused on learning about all the new antirejection medications that would keep his new kidney healthy. He was eager to get on with making up for the six years he lost to dialysis. The six years he had to curb his ambition and planning for the future because he didn’t know what the next hours, days, weeks, months, years would bring.

  But on the second day, things changed.

  The urine flow into the collection bag slowed to a trickle, then stopped altogether. Every few hours the nursing assistant would weigh him, and each time his weight would be two and four pounds higher than the last time. Something was wrong.

  He was taken to the radiology department for an ultrasound that afternoon. It showed hydronephrosis—a significant amount of urine had backed up so that the kidney’s pelvis, the central part of the kidney that normally funnels urine to the ureter (the tube that funnels urine to the bladder), looked like it was stretched to more than twice its normal size. Because the capsule enclosing the kidney will stretch only so much, the ballooned pelvis would press against the urine-making parts of the kidney. Pressed long enough, these parts would wither and eventually die.

  Not long after Robert was returned to his room, a team of rounding doctors filed into Robert’s room, with more spilling into the hallway. By the lengths of white coats and amount of gray hair, it was clear there was a pecking order. The long, knee-skimming white coats and white hair of attending physicians in front and short coats just clearing the waists of the blond and brunette medical students bringing up the rear, straining to hear what was being said.

  “There is a blockage,” said the transplant nephrologist leading the pack, his face concerned, his demeanor confident. “It’s the reason why you’re not producing as much urine as we’d like. We’d like to go in and see what’s going on. The urologist is here.” He gestured to the long-coated, salt-and-pepper-haired man to his left. “He’s taken a look at your ultrasound and the blockage is somewhere in the connection to your kidney.”

  This was not supposed to happen. This was a surgical complication.

  About a half hour before Frank walked into Operating Room 17 to find me, Kobayashi had entered Operating Room 18 to find Robert lying on his back where the kidneys he was born with, his native kidneys, lay shrunken like grapes withered on the vine, which is where they would stay. Only native kidneys causing problems are removed. Problems like an infection that won’t go away. Or like the problems common to people who have inherited polycystic kidney disease, whose kidneys are nearly completely taken over by large cysts. Cysts that often bleed and cause pain and make the kidneys huge, like footballs, when a normal kidney is the size of a fist.

  Robert was unconscious and paralyzed. Tubes already inserted. One down his throat for breathing. A smaller one in his neck for delivering the first antirejection medicine into his bloodstream. Another threaded up his penis to collect all the urine that was soon to come. Kobayashi’s assistant, the surgery fellow, had already shaved and cleaned Robert’s belly. He was ready for sterile drapes to be laid across.

  Kobayashi expected that his assistant and he would make their incision about an inch above his right hip bone and cut diagonally down parallel to the thigh crease, then methodically cut through fat and muscle and tease apart connecting tissue until they had clearly exposed the parts of the pelvis they were looking for—a length of large artery and vein near the bladder. Parts ready for transplant.

  Minutes later Kobayashi would return with the new kidney resting soft and pale pink in a bowl of cold slush and head to the back table, where he and his assistant would get the kidney ready to transplant. This wouldn’t take long—kidneys from living donors don’t require as much work to isolate their artery and vein, tie off extra vessels, or strip away a lot of fat like deceased donor kidneys require. All those extra parts make it harder for the living donor’s surgeon to pull the kidney through a small bikini-line incision.

  Not trusting the kidney in the hands of the assistant, Kobayashi would carry it himself to Robert’s awaiting pelvis. He would lay it in the wound to judge its best position, given the length of transplant artery, vein, and ureter he had to work with. Once decided, his assistant and he would peer through magnified lenses mounted to their headpieces fitted with spotlights and sew the finest of stitches to connect vein to vein, artery to artery. Hands steady. No room for error. When the clamps were unclamped, he expected the kidney would be already “pinking up” with blood flow restored. It would be firmer too. They would watch urine dribbling out of the ureter. This is a good kidney, they would think.

  Next they would attach the donor ureter. At this hospital, they almost always attached donor ureter to recipient bladder. Today would be no different.

  “OK, ready to distend the bladder,” Kobayashi would instruct, and the anesthesiologist would turn the clamp on the bladder catheter to “fill” position, and an antibiotic-laced fluid would flow into Robert’s bladder. Though it hadn’t had to fill with urine in the more than five years that he’d been on dialysis, with just under two cups of fluid, the bladder would appear like a balloon being blown up into view. Next he would cut a hole in the bladder, sew the transplant ureter into it, and wrap t
he two with a strand of muscle. This would both stabilize this new connection and mimic nature.

  “Ready to unclamp,” he would say, and the anesthesiologist would turn the catheter clamp a quarter turn. Urine would flow.

  However, instead of a smooth dissection down to vessels and bladder, Kobayashi found layers of scar tissue and mesh stuck together in the right side of Robert’s pelvis—perhaps not surprising given that he had two hernia surgeries on the right side. He found it almost impossible to get through. There was the left side, where they often operated for people who had prior surgeries or blood vessel blockage on the right, but that would mean starting a new dissection and the blood vessels on that side would be a little harder to work with—so connecting my ureter to Robert’s ureter seemed the best option. Kobayashi rarely did this in his practice, but other transplant centers often did. He thought about putting in a stent, a wire mesh that would protect the new connection and hold it open. He tried, but the angle of the connection was too sharp. It was almost impossible to get the stent past it, so he decided not to persist. After all, urine didn’t need a straight path to flow, so he thought it would be fine.

  But on that second day after surgery, that connection was kinked like a garden hose that no water could flow past. The kink had caused urine to back up in the kidney. The kink had caused urine to leak into Robert’s pelvis. The kink was the reason why Robert had stopped peeing and was becoming more and more swollen.

  On the transplant nephrologist’s cue, the urologist took over to explain what they wanted to do. They hoped to straighten out the connection between my ureter and his ureter without having to reopen his surgical wound. Robert listened intently, welcoming the notion of the problem being fixed.