"Do you think we've got another Brazilian lawyer here?" Rob said then. He had got up and had walked over to the X-rays and he was pointing to the shadow at the inner edge of the upper lobe of the right lung, just above the root. "Do you think he's another Roberto Leon?"
"We can't tell from those," he said. "He may be."
"I've been thinking of that little Brazilian lawyer for a year now," Rob said.
"I have, too," he said, "but it's more than a year. It's about eighteen months."
"It's a funny thing," Rob said. "I wouldn't want to wish it on a dog, but I'd like to see us do another one some time."
"We've got four live dogs in the lab to prove we can do it," he said.
"Mr. Scheller may be the one at that," Rob said.
"We'll know on Wednesday," he said.
Mr. Scheller may indeed be the one, he had thought, driving home that night. His symptoms indicate it's even more advanced than that Roberto Leon's and, as Rob says, we've been waiting for another one to invade the superior vena cava and Mr. Scheller can be the one. If he is we can do it. I know we can do it and, as Rob says again, I'd like to bring it off some time and this could be the one.
"I'm glad to meet you, too," Mr. Scheller's son was saying now, standing beside his mother in the lounge. "We just wanted to wish you luck, Doctor."
"I thank you," he said, "but I don't want you and your mother to worry now. Your father's going to be all right."
"I certainly hope so," Mrs. Scheller said, shaking her head and trying to hold back the tears.
"Now look," he said. "As I've told you, I've done thousands of chest operations and I'm going to take the best of care of Mr. Scheller."
"I know you will, Doctor," the son said.
"I'm sorry that we've been delayed," he said, "and you two don't have to stay here. You can go home and come back in about four hours. If you're not here when we've finished either Dr. Robinson or I will call you to give you the report, and perhaps you can see Mr. Scheller this evening."
"I certainly hope so," Mrs. Scheller said, still shaking her head and blinking back the tears.
"Now please," he said. "You must believe in me."
"I do, Doctor," she said, nodding and shaking his hand. "I'll try not to worry so much."
"And you too," he said, shaking hands with the son. "You take care of your mother. I'll take good care of your father."
"I know you will," the son said, "and good luck again."
"Fine," he said.
I hope I don't have to count on my luck, he was thinking, walking away, but I know what they mean when they always wish you luck. You count on your skill and it's only when you come up short on skill that you need your luck. If we've got another Roberto Leon here I know I've got the skill now and I won't need that luck we could have used then but didn't get. That was one day when we certainly didn't pull any luck.
XVII
"What time is it?" he had said that evening, walking down the hall from the operating room.
"7:45," Bob Robinson said.
He had worked it out, then, the simple mathematics of it. At 1:00 they had opened Roberto Leon and at 7:30 they had lost him.
"I'm bushed," Bob Robinson said. "You know that was six and a half hours?"
"I know," he said. "I'm tired, too."
They both knew, without saying it or without it even becoming a conscious thought, that it was not the hours alone but the empty frustration of failure that was the catalyst of their fatigue. Often, after an emergency, he had walked out of the operating room at 3 or 4 o'clock in the morning so exhilarated that he knew he would be unable to sleep and wishing that his regular operating schedule for the day could begin then and not five or six hours later.
"I'll phone it in," Bob Robinson said. "I just want to get out of this suit."
"No," he said. "I'll phone this one in myself."
"Whatever you say," Rob said.
"I'll see you back at the office."
"Don't you want to eat?"
"Maybe later," he said.
He went into the booth next to the nurses' station and closed the door. He sat down and picked up the phone and heard the dial tone. When he dialed 7 the tone altered to a higher pitch and when he dialed 1 the tone ceased and he knew that the recorder in the booth in the office downstairs was turning and that he had five seconds in which to begin talking.
"Patient's name," he said. "Leon. L-e-o-n. First name, Roberto. Date, May 11, 1960."
Exactly one week before, Roberto Leon had walked into the office for the first and, as it was to turn out, the only time. He had flown up from São Paulo alone, bringing with him, in their large brown envelope, his X-rays. He was forty-six years old, five feet five inches, swarthy, dark-haired and dark-eyed, and he spoke excellent English, with only that typical rising inflection at the end of his sentences. The shadow in his right lung had been picked up three weeks before in a routine examination by his doctor in Brazil, and his only symptoms were an unproductive cough and some pain in his right shoulder.
"You think it is cancer, Doctor?" he had said at the end of the examination.
"I can't be sure at this point."
"As I told you, I am a heavy smoker."
"If you're convinced of the correlation between smoking and lung cancer, why don't you give up cigarettes?"
"That's what you call the calculated risk," Roberto Leon said. "I work hard at my profession and I enjoy smoking. I am not concerned with just life alone but with living. Smoking a lot and drinking perhaps a little more than I should are among the pleasures of living for me. Can you understand that?"
"I understand perfectly."
"I think too many people deprive themselves of living just to live," Roberto Leon said. "Then you will have to operate?"
"Yes. I have to get in there to see what this is."
"Then you have to operate. When can you do this?"
"I can do it as soon as we can get you a room at the hospital. Can you go in within the week?"
"Yes. I have several days' business with an associate here for whom I do work in South America, but after that I am ready."
"You told me that you're married. Did your wife come up from South America with you?"
"No, because she does not care for airplane travel, but she understood that I might have to have an operation."
"And a major operation?"
"Oh, yes. You were highly recommended to me in São Paulo, and I am aware of your reputation and I have confidence in you."
"That's good to know."
"Oh, yes. They have explained to me, because I asked, that if it is cancer you may have to take out my lung."
"That's correct, but we don't know that yet."
"If you have to take out the lung," Roberto Leon said, "you have to take out the lung. I have confidence."
"Good," he said. "I have confidence, too."
Not many of them make it as easy for you as that, he had thought after Roberto Leon had left, and I like this little guy. He's the manic type and decisions come easy for him and if he were not a good lawyer and had the skill in his hands and the liking for it he would have made a good surgeon. All the best ones among us are that same type.
When he opened Roberto Leon he found that the cancer had spread from the lung to the pericardium, the covering over the heart, and to the superior vena cava, the large vein that drains the blood from the upper half of the body to the right atrium, or chamber, of the heart. It covered the lateral and anterior, or side and front, walls of the superior vena cava over a longitudinal area of about two and a half centimeters, or almost an inch, and so he knew that he could not simply remove the infected section and sew the two severed ends back together because the tension would be so great that the sutures would tear out.
It was a problem he saw about once every two years and it had been baffling him as it had the rest of the profession which had been talking about it for twenty years. To leave the cancer there would mean death for Roberto Leon within
six weeks or two months. Those surgeons who had tried plastic grafts or bypasses had found that, because the body tends to reject a foreign graft and because the blood flows so slowly in the vena cava, as in any vein, the blood had clotted and the patients had died within three days.
"What do you think?" he said to Bob Robinson.
"I think he's got just one chance, Matt."
"You're right," he said, "so we have to give it to him."
They had been working on an experimental procedure on and off for several months. One evening after they had closed another patient, forced again to leave the cancer-invaded superior vena cava, it had come to him suddenly and he never knew why or from where, that, although foreign grafts had failed, a graft made from the patient's own right pulmonary artery might be completely compatible.
"After all," he said to Bob Robinson the next day, "when we take the right lung we're also taking the right pulmonary artery."
"You know something, Matt?" Rob said. "You might just have it."
"It's worth a few hours in the dog lab, isn't it?"
"I'll say," Rob said.
The next Saturday morning they tried it for the first time in the old red brick wing that had been the original hospital building, with the animal smell hovering there and with the intermittent chorus of barking coming through the two doors between them and the kennels. In a human being the superior vena cava and the right pulmonary artery are, in diameter, about the size of a man's thumb. In the animal that they used, the two vessels were about as big around as a lead pencil, and when they had removed the right lung and its artery he fitted the section of the artery to be grafted over a three-inch length of polyethylene tubing at the ends of which he had flared a collar or flange with the heat from a match flame. His plan was to clamp off the superior vena cava to stop the flow of blood, remove a section, insert the tubing, and snare it at both flared ends. Then he would release the clamps, which would permit the resumption of the flow of blood through the tubing and prevent damage to the brain. He would suture the ends of the artery to the ends of the vena cava, but just before he put in the final sutures, he would clamp the vena cava again, remove the tubing, finish the graft, and release the clamps.
It failed. It failed because, when he severed the vena cava, the ends retracted and the vessel collapsed and, before he could bring the ends close enough to place the tubing, snare it, and remove the clamps, the damage had been done to the brain. While the carotid artery had continued to pump blood into the brain the clamps had prevented it from draining out.
"But there's got to be a way, Matt," Bob Robinson said. "It's just a matter of procedure."
"I know," he said. "We've got five minutes, at the most, while that clamp is on. I should have left a floor in the vena cava."
What he meant was that, instead of cutting through the vena cava, he should have made two cuts, one at either end of the section to be removed, but that each cut should have been only about two thirds of the way around the vessel. The wall that remained would prevent the retraction and provide a floor on which he could slide the tubing into place.
"That'll work," Bob Robinson said. "We've done that with the aorta."
"I know," he said. "Tell me why I didn't try it here."
The following week they tried it and it worked. About a month later they were successful with another dog, and so they had two living animals to prove they could do it when he decided, because he had no other choice, to attempt it on Roberto Leon.
What happened then he would never forget. He had placed the tubing with its sleeve of artery around it and he had snared it at both ends. He had removed the section of vena cava containing the cancer and, with the tube in place and the blood draining again, he was sewing the bottom of the arterial section to the lower portion of the vena cava when he saw the blood and heard Bob Robinson.
"Christ, Matt!" Rob said. "The tube's popped out!"
"Clamp him," he said.
The tube had slipped its snare at the upper end. With the vena cava clamped again he knew how much time he had, but trying to bring down the retracted and collapsed end of the vena cava and trying to get it back over the end of the tube was like attempting to fit the taut neck of a toy balloon over something larger than itself.
"His pressure's dropped, Doctor," the anesthetist was saying. "It's down to 60 now and his pulse is extremely weak."
"All right," he said. "I'm having trouble but I'll get it."
"I'm sorry, Doctor," she was saying, "but his face is puffy and his eyes are bloodshot. His color is terrible. He's as blue as ink."
"I'll have this in a moment," he said, keeping his voice even and trying to assure her and the rest of them. "I'm getting it now."
He got it, but not in time. He got the tube back in and completed the graft, but the blood pressure never responded. When it became imperceptible they tried, for an hour, intermittent manual massage of the heart and then ten grams of calcium through the intravenous tube and then an injection of one c.c. of 1:10,000 dilution of adrenalin right into the heart.
"I'm sorry," he said, finally, suddenly feeling his own emptiness and then aware that the whole room had gone flat around him. "He's gone. What's the time?"
"It's 7:30," Bob Robinson said. "I'm sorry, too, Matt."
That was all they said. It took them about fifteen minutes to close the chest and sew back the skin. Out of habit, because it is the right way to close a chest, and out of respect for the body, they used the same interrupted-silk technique they would have used if they had been successful and Roberto Leon still lived. Then they were walking down the hall and he again asked the time and then went into the booth to start dictating the report.
Twelve paragraphs and as many minutes later, his sweat drying on him now and conscious of the chill, he was at the end. When he paused then, silent for more than those five seconds at which the timing mechanism of the recorder is set, he heard the shrI'll whistle in the receiver.
"At 7:30 p.m." he said, and the high-pitched whine stopped, "six and one-half hours after the beginning of the operation, the patient was pronounced dead. The chest was closed in layers with interrupted-silk technique. Dictated by Matthew Carter, M.D."
So that's that, he was thinking, walking to the locker room, and when I get back to the office I've got to call that associate of little Mr. Leon. I've got to call and tell him and find out if he'll call the wife in Brazil or whether I should. I don't even know whether the woman speaks English and my poor bastardized Spanish won't stand up to that. They speak Portuguese down there anyway, although, if she's like her husband, she probably speaks Spanish and maybe even English, too. If she doesn't speak English he'll have to do it.
Rob put that snare in, he was thinking, but I don't think it was the snare. After the tube slipped and I had to take that snare off, it seemed tight enough, and if it wasn't the snare it had to be the flare on the tube itself. We did those three dogs the same way but, for some reason, the flare on that tubing just wasn't big enough, and that has to be it.
His own office was dark but there was a light in Bob Robinson's. Bob Robinson was sitting at his desk, looking through his mail, and sipping at a drink. He had mixed another, and it was standing on the corner of the desk with the ice and the twist of lemon in it.
"You know, Matt," he said, "what makes it such a damn shame is that we can do that thing."
"I know we can," he said, "but we didn't."
"I've been sitting here thinking about that snare," Rob said.
"It wasn't the snare."
"I'd have sworn I had it tight enough."
"You did. It wasn't the snare."
"I took two turns around it before I tied it down."
"It wasn't the snare," he said. "I could tell it was tight enough when I took it off. It had to be the flare on the tubing."
"But why?" Rob said. "It looked all right to me."
"It looked all right to me, too, but obviously it wasn't flared enough and my technique wasn't smooth enough
, either. If I'd been smoother putting those sutures in below it never would have popped out above, even with the flare it had on it."
"I don't know," Rob said. "I'm not sure."
"You know it as well as I do."
"But let's face it, Matt," Rob said. "If we hadn't tried it he'd have been done for anyway."
Oh, come on, Rob, he thought. You're saying that I didn't kill him; that I just didn't cure him, but what difference does that make right now to little Mr. Roberto Leon, who had all that confidence in me, and to his wife down there in Brazil?
"You know what I've thought occasionally?" he said.
"What?"
"The profession to be in is civil engineering."
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