"Good-bye," he said, and then: "Orphan Annie?"
"Yes, Doctor."
"I'll let you take ten breaths for our patient and then stop."
"All right."
"Stop."
He cut a half-inch off the satin-white toughness of the tubelike, horseshoe-shaped bronchus to get beyond where the clamp had crushed the tissue and to permit him to make the closure flush with the trachea, or windpipe. As he made the cut he left the floor of the bronchus extending out slightly like a tongue to allow for the recoil, and then he forced the curved needle and the first suture through the middle of the roof and the floor and pulled the floor up tight. He knotted the wire three times and took the sponge stick, the clamp with the gauze, and pressed it over the opening.
"Now you can take ten more breaths," he said. With the gauze he was blocking the contaminated air from the mouth and pharynx from getting into his field, and he could count the breaths by the rhythmic gurgle of the moisture in the trachea. "Okay?"
"Yes, Doctor."
He put the eight other sutures in the same way. He spaced them evenly so that each would carry the same load, stopping after each for Orphan Annie.
"All right," he said, finally. "The bronchus is closed. Saline wash, please."
Now he would test it. Now he would see if he had really closed it so that none of that contaminated air could possibly get into this chest, and he took the pan of saline from the scrub nurse and, tipping the pan, he poured the solution into the open chest until it covered the stitches against the trachea.
"Now see if you can make it leak, Orphan Annie," he said. "I want you to push hard on your bag. You ready to push?"
"Yes, Doctor."
"All right, push. Push hard. Are you pushing, Annie?"
He watched the surface of the saline solution above the stiches. There were no bubbles.
"I'm pushing hard, Doctor," he heard her say.
"Okay," he said. "You can stop. Good girl."
He looked at the clock on the wall. It was 12:21.
"I think," he said, "that at this point he should have had two transfusions. Am I right, Orphan Annie?"
"He's just finishing his second, Doctor."
"How is he?"
"He's all right, Doctor. His blood pressure is 110 over 80."
When Bob Robinson and Darrow had finished draining the area with the tonsil suckers he began to isolate the superior vena cava. He was liberating it from its bed, the vein as big around as his thumb, thin-walled and the blueish-black of its used blood showing through, draining back to the heart.
"Now, Mary," he was saying, "I want you to have ready the largest of those three pieces of polyethylene tubing you've had soaking, the one about the size of my ring finger."
"Yes, Doctor."
"And where's our good float?"
"Right here, Doctor," the floating nurse said. She was kneeling, opening the used blood-stained gauze sponges and spreading them, to be counted on the drape on the floor in the comer.
"I want you to go out and get a pack of matches. You and I are going to light a camp fire in the scrub room."
"Yes, sir."
"There's a bleeder, Matt," Bob Robinson said. "I'll get it."
"And Mary?"
"Yes, sir."
"I'll want you to have your two lengths of umbilical tape ready and those two lengths of the small tubing. Also your four-o silk with atromatic needles, twelve of them."
"Yes, Doctor."
He had finished freeing the vena cava, and when he looked up the floating nurse was coming back from the scrub room. She held up a pack of matches and he nodded.
"Now let me have that tubing, Mary."
That cancer involves a half-inch, he was thinking, taking the forceps with the tubing in it, so I'll resect an inch. That will give me a quarter-inch margin on either side and if I make the tube about three inches long I'll have enough room to snare it and it won't be so long that we'll have trouble getting it out.
"Scissors," he said, and with the forceps holding the tube in his left hand he cut through it.
"All right," he said to the floating nurse. "Let's go."
She held the door to the scrub room open. He walked through, holding the tube in the forceps, and waited for her to let it swing closed again.
"Now just light a match," he said, "and hold it steady."
When she had lighted the match and held it out to him, he rotated one end of the tube just above the flame. As he turned it he saw the end swell and flare up and out into an even, encircling collar.
"Very good," he said, withdrawing the tube. "Now blow out that match and light another one."
"Yes, sir."
"Good girl," he said when he had completed the flared flange at the other end. "You've just won your merit badge for outdoor camping."
"Thank you, Doctor," she said.
So this is it now, he was thinking, as she opened the door for him. What it all comes down to now is just six minutes, at the most, just those two three-minute intervals, and we can do it because we've got those dogs to prove it and because I know we can do it.
"Now, Mary," he said, the others watching him, "let me have that right pulmonary artery you've been taking such good care of."
"Yes, sir."
"What we're going to do now," he said, fitting the section of pulmonary artery over the three-inch length of flexible, translucent tubing, "is this. We're going to put two clamps on the superior vena cava which will give Orphan Annie a little trouble. We're going to open the vena cava between them, slide in this plastic tube with the artery, snare the vena cava around the ends of the tube, and remove the clamps. Then, with the tubing serving as a temporary conduit so that the blood can drain through it, we're going to resect an inch of the vena cava, including the cancer, and put in the first sutures to make this graft. After that well clamp him again to annoy Orphan Annie, remove the tube, close our final sutures, and unclamp him. Clear, Annie?"
"Yes, sir."
"His blood pressure still all right?"
"Yes, sir."
"Now you know it's going to fall and he's going to turn blue when we restrict the blood from returning to the heart, but we won't keep him clamped for more than three minutes at either time. If I'm any good it'll be less."
"I understand."
"Now I've got another job for you," he said, turning to the floating nurse. "You're the timekeeper. When I tell you, I want you to watch that clock. Once I say: 'Go, I want you to call out to me at the end of each minute. Call out: 'One minute! Two minutes! Three minutes!' I don't think we'll get to three, but if we do you call it out. Clear?"
"Yes, Doctor."
"And, once we start, don't take your eyes off the clock."
"No, sir."
"Now you hold this, Doctor," he said to Darrow, passing him the forceps holding the tubing with the sleeve of artery over it. I'll take it from you when I want it."
"Yes, sir."
"Now let me have the umbilical tape," he said to the scrub nurse, "and then one of those smaller tubes and a small clamp."
It is like a thin white shoe string and he placed the first tourniquet-like snare around the vena cava close to the heart. He wrapped it around twice, loosely, and did the same for the second snare, three inches above the first and above the cancer plaque.
"I'm leaving them loose enough," he said to Bob Robinson, "so you can shift them as much as you have to before you snare them down."
"Good," Bob Robinson said, holding the two vascular clamps, one in either hand.
"Everybody set now?"
"Right, Matt," Bob Robinson said.
"Yes, Doctor."
"Scissors," he said. "Watch that clock. Go!"
He watched Bob Robinson put the first clamp across the vena cava above the upper snare. He watched him place the second below the lower snare and close to the heart, and then, pinching the superior vena cava above the cancer between his thumb and his index finger, he made the first cut with the scissors
halfway across it, about a quarter of an inch above the cancer plaque. Then he pinched below the growth and made another cut but again going just halfway to leave the remaining portion as a floor on which he could slide in the polyethylene tubing. Then he made the longitudinal cut between the other two just outside the edge of the cancer.
"All right," he said, and then to Darrow: "I'll take that now."
With the forceps holding the polyethylene tubing and its artery in the middle, he slid the upper end into the opening in the vena cava and pushed it up until he felt it meet the upper clamp. Then, bending the tubing a little, he worked the lower end into the opening and straightened the tube and slid it down toward the heart.
"One minute, Doctor."
"Thank you."
"Take it down a little more, Matt," Bob Robinson said.
"Okay," he said, lining it up with the lower snare and thinking: We're doing fine. If I can just keep this lined up in position for this snare we'll do fine.
"It's good up here, Matt," Bob Robinson said.
"Then snare it, and I'll get this one," he said. He had to slide the umbilical tape up slightly to position it and then he pulled up on the snare, tightening the vena cava under it around the plastic tubing just within the flange at his end.
"Snared here," he said, removing the vascular clamp across the vena cava below the tube. "Unclamp him up there."
"Got it," Bob Robinson said.
"Two minutes, Doctor."
"Good," he said. "You can forget the clock now until I need you again."
"Very nice, Matt," Bob Robinson said. "Just about two minutes flat."
"Orphan Annie?" he said. "Our patient get blue?"
"Yes, Doctor."
"What's his pressure now?" he said. He was completing the dissection around the vena cava, above and below the growth.
"It dropped to 90, but it's beginning to come back up."
"His color improving?"
'Yes, Doctor."
"Here's our troublemaker," he said. Holding the severed one-inch section of the vena cava in the forceps, he turned it over, looldng at it, and then handed it to the scrub nurse. "Now I'll need some three-o silk for two traction sutures."
He placed the first traction suture through the superior vena cava near the lower cut, tied it and passed the two long threads to Bob Robinson. Halfway around from the first and toward Bob Robinson's side he placed the second, tied it and handed the threads in their snap to Darrow.
"Just hold these loosely for me now," he said, and then to the scrub nurse: "That four-o silk and atromatic needle."
Now this is where we lost before, he was thinking, watching the vena cava rotate, its bottom side exposed as Bob Robinson pulled on his traction suture. It was right here, while I was doing these lower stitches that the tube popped out above and we had to reclamp and I lost Mr. Roberto Leon.
"You'll keep an eye on that upper snare, Rob?"
"I'm watching it. It's fine."
He started his first stitch through the vena cava and picked up with the needle the lower end of the sleeve of artery. Using a running stitch and sewing toward the under side he went a quarter of the way around and then passed the thread under the vena cava and picked it up on the other side.
"It's fine, Matt," Bob Robinson said.
"Good," he said, and then to Darrow: "I'll take that traction suture."
Pulling evenly, he saw the vena cava rotate the other way, toward himself and Darrow. He turned it until he could see the last bottom stitch he had put in.
"Just keep that same traction on," he said, handing the threads with the snap on them to Darrow.
"Yes, sir."
He completed the sewing of the bottom side. He took the traction suture from Darrow, allowed the vena cava to revert to its normal position, finished sewing across the upper side and tied it.
"Very good, Matt," Bob Robinson said, cutting the thread.
"Thank you, my friend."
He did the same at the top of the graft, except that he used the running stitch along the under side only. On the upper half he put in eight interrupted, or individual, stitches, pulling the threads all up together, putting a snap on them but leaving them loose, the polyethylene tubing showing between the stitches in the gap between the vena cava and the artery.
"A wipe for Dr. Carter," he heard Bob Robinson say.
He waited, aware for the first time now that he was sweating, while the floating nurse wiped his brow with the gauze.
"Thank you," he said. "How's he doing now, Orphan Annie?"
"All right, Doctor. His pressure's up to no over 80 now."
"Good," he said, "but now I've got to give you trouble again. We're going to clamp him once more to complete this graft. We were two minutes doing the first half, so we should be under two this time."
"Yes, Doctor."
"Is my timekeeper ready again?"
"Yes, Doctor," the floating nurse said.
"Now, when I say: 'Gol' you'll count off the minutes again."
"Yes, Doctor."
"Everybody else ready?"
"Right, Matt."
"Yes, Doctor."
"Vascular clamp," he said. "Watch the clock. All right Go!"
He placed the clamp on the vena cava above the upper snare. He loosened the upper snare and discarded it and saw Bob Robinson had removed the lower one.
"Good," he said. "Now pinch it. Forceps."
He watched Bob Robinson pinch, between the thumb and forefinger of his left hand, the vena cava around the polyethylene tubing near the lower end and at the entrance to the heart. It was the way they had rehearsed it four times in the dog lab, Rob to pinch it hard enough to restrict any heavy back-flow of blood from the heart, but still permitting him, as he himself worked from the other end, to force the lower end just inside the entrance to the heart and down low enough to expose the upper end in the open upper suture line and extract it.
"Let up just a little," he said.
"Enough?"
"Good."
Sliding the tube down, forcing it ahead of his fingers as he squeezed the vena cava above it, he could see its upper end now at the loose upper suture line. With the forceps between two of the ties and grasping the top of the tube he withdrew it, some blood coming with it, but the blood stopping when Bob Robinson placed the lower clamp across the vena cava close to the heart. Then he picked up the snap holding the eight single sutures and pulled them up tight.
He removed the snap and started to tie the three knots on the first of the eight. He put in the first knot, felt it give a little under the second and put in the third. As he tied them he passed the long ends to Darrow.
"Just hold these," he said. "We'll cut them all together."
"One minute, Doctor."
"Good."
He did them all like that, putting in the three knots, passing them to Darrow. When he had finished seven he straightened up.
"Okay," he said. "Unclamp him below."
When Bob Robinson removed the clamp close to the heart he saw the vena cava fill up from below, then the bubbles of blood in the opening around the last loose suture as the rising blood forced the air out ahead of it. As the blood started to come he pulled the last suture up, tied it three times, and saw only the small leakage around the suture line.
"Got it," Bob Robinson said, reaching above and removing the upper clamp, the blood starting to drain now through the vena cava, through the graft and into the heart.
"Two minutes, Doctor."
"Oh," he said. "Thank you. I forgot to make the grand announcement. The graft is completed."
"That was nice, Matt," Bob Robinson said, cutting the sutures above the knots. "That couldn't have been more than a minute and fifty seconds."
"How's our patient, Orphan Annie?"
"His pressure is coming back, Doctor. It was down to 90 again."
"Color improving?"
"Yes, Doctor."
He placed the white strips of Surgicel over the suture l
ines at the top of the graft and then at the bottom. It would seal off the small bleeding around the needle holes and, finally be absorbed by the body.
"That's a beautiful graft, Matt," Bob Robinson said.
"It looks good to me, too," he said, examining it, and then to Darrow: "You understand that we had to use the patient's right pulmonary artery because the body tends to reject a foreign graft in the veins and when they've been tried in the past the blood has drained so slowly through the vena cava that they've been ineffective."
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