The surgeon

by Wilfred Charles Heinz

  "I understand, sir."

  "Now we've got to patch that pericardium."

  With the index finger of his right hand he reached between the chest wall and the pleura adhering to it. Freeing the pleura, smooth and more fragile than the heart's own natural covering that he would repair, he cut a rectangle approximately the size of the opening he had made in the pericardium when he had removed the growth. This patch, translucent and not unlike the latex of his gloves, he spread on the towel to his left and in front of Darrow. Into each of the four comers of it he looped a silk thread, and holding the patch up by the top threads, the bottom threads dangling, he laid it over the opening with the bare heart beating in it, now covering the heart.

  "Now Dr. Robinson will just keep a little tension on it," he said, passing the two top threads to Rob. Then he took the bottom threads and adjusted the patch. He sewed the four comers, then stitched the bottom and the other three sides.

  "Any good tailor would be appalled by the crudeness of this," he said for Darrow, "but it will keep the heart from herniating out through the opening, and that's what it's for."

  He had lost one that way about ten years before. It was that white-haired old man whose son had brought him all the way from Ireland. The old man had never spent a night away from his wife since they were married. He had never been out of his own country before and it was the spring of the year. The old man had charmed them all with his smile and his old country expressions and his laughter, and when he had lost him, that morning he would never forget, he had walked the son down to the end of that fourth floor and they had stood, each with one foot up on that radiator by that low window with the rod across it, and he had tried to explain it. The son had taken it with his face set and nodding, and then they had shaken hands and the son had left. Alone, he had stood there for a long time, looking up the river, alive in the sunlight. Across the avenue the trees were just coming to bud, and he had thought of how green they say Ireland is in the spring and then, perhaps for the last time, he had felt tears in his eyes.

  "Besides," he said to Darrow, "in a few days this patch will grow right into place."

  "I understand, sir."

  "That's that," he said, and to Bob Robinson: "You care to put the tube in?"

  "Any time," Bob Robinson said. "Let's lift this stockinet."

  He released the clamp holding the stockinet and, lifting the stockinet, he watched Rob take his bearings from the marker clip he had put on the skin towels during draping and make his stab wound between the fourth and third ribs. He watched him tunnel up with the long, curved Carmault clamp and over the top of the second rib into the chest, then feed a corner of one end of the tube into the clamp inside the chest and pull the tube out.

  "This is just a decompression tube," he said to Darrow. "We place it at the top of the chest so that, as the body fluid fills the chest, it can be undamped occasionally to let the air out. We'll remove it in about thirty-six hours, and after several weeks that fluid will form a semi-solid jelly in there."

  "Yes, sir."

  "Now we're going back to that serial dilution of bacteria you learned in first year bacteriology," he said, and then to the scrub nurse: "Let me have that pan of saline."

  "Yes, sir."

  "Let's say there are ten million bacteria in there," he said, tipping the pan and pouring the saline into the chest. "Now you people suction this out and there'll be only ten thousand left. Then we'll fill the chest again, suction that out and we'll have only a thousand. The third time we'll be down to ten, and the fourth time to two lonely survivors. Right?"

  "Yes, sir."

  "Who's throwing things around here?" he said, hearing the bottle land in the plastic waste basket behind him.

  "I am, Doctor," the scrub nurse said. "It's just a saline bottle."

  "You mad at me, or something?"

  "No, sir."

  "All right," he said, after they had drained the chest with the tonsil suckers for the fourth time. "Now I'll shake this antibiotic powder in here to kill those last two bacteria, and if Dr. Darrow thinks that any organisms are still alive in that environment, I want him to speak up."

  "I'd say you've got them, sir," Darrow said.

  "How's our sponge count?"

  "The sponge count is correct, Doctor," the floating nurse said.

  "Then let's crank him closed."

  It's 2:29, he thought, looking at the clock, and that's not bad. We can close in twenty minutes, and I can see Mrs. Scheller and her son and be out of here by 3. They won't be opening Mrs. Pappas until 3, so I'll be there in plenty of time.

  He watched Bob Robinson turn the handle of the rib spreader and take it out. He watched him examine the walls of the incision for any bleeders and then put in the rib approximator, hooking one prong at each end behind the fourth and sixth ribs on either side of the opening left by the missing fifth rib. He watched him turn the handle and bring it abnormally close together in the center to get the ends as close as possible.

  "Now we can go back to our one-two-three," he said to Darrow. 'Your two-o silk, Mary."

  Sewing through the intercostal muscles he brought together the edges of the periosteum that would regenerate the new rib. Then he restored the other muscles to their normal position, with the needle holder in his right hand casting the loose thread toward Rob as you would a trout fly, sewing through the tough fascia above and below each muscle and just catching a piece of the muscle, picking up the needle on the other side in such a way that, when he passed the empty needle to the scrub nurse, she could rethread it without having to unclamp the needle holder and reposition it, sewing the next interrupted stitch while Bob Robinson, the sutures always landing right in front of him, tied the previous one.

  "And now we reconstruct our auscultatory triangle," he said to Darrow, who was cutting the ties for Rob. "There isn't any lung to listen to any more, but it's still a landmark for our reconstruction."

  "Yes, sir."

  "Orphan Annie? Can we have that right arm?"

  "Yes, sir."

  "Good," he said, seeing the shoulder move back toward normal, and then to Darrow: "Now, if you know your anatomy and the mechanics involved here you don't have to be a tackle for the Packers or the Giants to hold up this shoulder."

  He showed him how, by placing the middle finger of the left hand on the acromion process, the bone running along the top of the shoulder, he could pull the shoulder up without moving the whole mass of the upper chest. Then he sewed the rhomboids and started on the trapezius muscles.

  "You've scrubbed with a number of doctors in this hospital," he said to Darrow, "so you've seen cancer in a variety of organs."

  "That's right, sir."

  "In the male over forty, what's the most frequent cancer of any organ?"

  "Well," Darrow said, "I was going to say cancer of the prostate or the stomach."

  "They're both close," he said, sewing the latissimus dorsi now, "but the answer is cancer of the lung."

  "Yes, sir."

  "And you know that cancer of the lung is a great mimic."

  "Yes, sir."

  "So what other diseases cause the symptoms this patient had: pain in the chest, although in his case it was high in the shoulder, blood in the sputum, loss of appetite, loss of weight?"

  "Well, TB and pneumonia."

  "That's right," he said. "You can relax on that shoulder now."

  He did the front edge of the latissimus dorsi, casting toward Bob Robinson, putting in the fifteen stitches. He had completed the triangle, and he waited while Bob Robinson removed the clamps and the stockinet, leaving only the drapes and, beneath them, the four skin towels framing the incision. Then, casting again and sewing through the fascia in the fat layer, he brought it together with thirty interrupted stitches.

  'Your four-o silk, Mary."

  With a straight needle, matching the cross-marks he had made across the first scratch almost three and a half hours before, he put in the first stitch and pulled the merthiolat
e-painted skin together. Bob Robinson matched the other marks, and the two of them, each starting from his own end, put in the final stitches, sewing and tying at half-inch intervals, closing the wound.

  "No," he said, as Darrow reached in and cut the threads close to the knot of the first tie. "We cut all the ties at once and about a half-inch from the knots so there's no chance of them coming undone."

  When they had finished and Darrow had cut the ties he waited while Bob Robinson washed off the incision with a saline sponge and covered the wound with a towel. They removed the drapes and the skin towels, and he watched Bob Robinson swab the wound with the yellowish-brown tincture of benzoin to assist the adhesion of the tape and to protect the skin.

  "Dr. Robinson likes to put it on the sutures, too," he said to Darrow, "so that if there are any organisms running around they'll get their feet stuck and be unable to reproduce."

  He placed the gauze, four thicknesses of it, covering the long, curved wound. He held it there while Bob Robinson pressed down the four-inch-wide elastic adhesive tape at the upper end, stretched it, pressed it down over the gauze and bordering skin and, letting up on the stretching, terminated it at the lower end under the right breast.

  "Rob," he said, "you're a gentleman. You've made me look good all morning, or is it afternoon?"

  "It's 2:35, Doctor," the floating nurse said.

  "Any time at all, Matt," Bob Robinson said. "It was a pleasure, and I think we really did something today."

  "Orphan Annie?" he said. "How is he now?"

  "He's all right, Doctor. His pulse is 82. His blood pressure is 120 over 80."

  "I have to get over to University," he said to Bob Robinson. "I'll check on him before I leave and see Mrs. Scheller and her son if they're here. If you'll look in on our other people I'll be back to the office by 5:30."

  "Sure, Matt."

  "will you dictate the op-note?"

  "It'll be a pleasure."

  "Thank you, all," he said, "Dr. Darrow and Orphan Annie and Mary and my good fire maker and timekeeper."

  "You're welcome, Doctor."

  The floating nurse was untying his gown and he slipped out of it and left it in her hands. He tossed the rubber gloves to her and pushed the door open. In the hall he slipped the mask down and untied it from around his neck, thinking: I should know her name. It's no good not being able to call them by their names and it used to be that I'd hear them once and remember them but it isn't that way any more.

  2:38 P.M.

  XX

  The locker room appeared empty, but as he started to undress he heard voices coming over the top of the row of lockers. He stripped out of his scrub suit and threw the shirt and trousers with the cap and mask into the canvas hamper.

  "I don't care what Ribicoff says," he heard one of the voices he did not recognize say, "and I don't care what Kennedy says, either. The moment anyone tries to tell me what patients I can treat or how many I can treat I'm getting out of the profession. I've been at this too long to . . ."

  He took his money out of his left sock and reached into his locker and put it in his wallet. He took his watch out of the other sock and put it on his wrist.

  "Of course they're not admitting to it now," the voice was saying, "but give them an inch and they'll take. . ."

  He dressed, aware for the first time, of a slight discomfort in his trapezius muscles, high in his shoulders. It was not the over-all tiredness he had known after Roberto Leon, after they had worked so hard for those six and a half hours and then lost, but just that small ache that he felt more often now in recent years.

  In fact I'd like to go right back in there and do another one, he was thinking. It worked beautifully, and I wish Stan or Bronson had seen it. That Darrow doesn't really know what he saw because he doesn't know how this thing has been licking us all for years, but there's no reason why, if we can get a clean artery like that, we can't do it every time. We know we can do it now, and if Mr. Scheller comes back like he should, if he doesn't fall off a scaffold or get hit by a cab in the next couple of months, I'll do a paper on it for the Journal. The trouble with doing a paper is that these days everybody is writing and nobody's reading, but this one is worth it and I'll do it.

  "So ask anybody in England," the voice coming over the lockers was saying. "Oh, I know there are some kids just out of school who like the security and the regular hours, but you ask any of the good ones how they like it and they'll tell you. . ."

  He had finished dressing and he walked out into the hall. He stopped at the nurses' station and waited for Sally Wheeler to finish talking on the phone.

  "Oh, it's you," she said, turning from the phone. "That was your patient's son. He's up in the room, waiting for news."

  "Call him back, will you?" he said. "Tell him I'll see him in the lounge up there in two minutes. I just want to check on his father in the recovery room."

  "I understand you did very well, a real tricky one."

  "I missed you, Sally, but I'll see you in the Bahamas."

  "After today," she said, "I'll need some kind of vacation."

  There were four of them in the recovery room, Mr. Scheller closest to the door. He was lying on his back, the sheet up to his neck, the head of the bed elevated in the semi-Fowler's position to encourage the flow through the graft, the intravenous tube running to his left arm from the suspended bottle of five per cent glucose in water.

  "Is he awake yet?" he said to the nurse.

  "Not yet, Doctor. He's starting to move but he hasn't really responded yet."

  "How's his blood pressure?"

  "Fine. He's 120 over 80."

  He lifted the sheet and picked up Mr. Scheller's right hand. He found the pulse was strong enough and regular enough and he saw that, while the skin color was still pale, the beds of the finger nails and lips were pink. He ran his thumb below the Adam's apple and into the sternal notch, that V at the top of the breast bone and, feeling the trachea, the windpipe, still perfectly centered he knew that the heart had not shifted.

  "will you feel in here once in a while?" he said to the nurse. "I just want you to check occasionally that the trachea is remaining in the midline."

  "Yes, Doctor."

  "Thank you."

  "You're welcome, Doctor."

  He walked to the elevator, waited for it, and then rode up to the sixth floor. As he stepped off the elevator he saw Mr. Scheller's son waiting for him right there and looking right at him.

  "I'm sorry, Doctor," the young man said, "but I couldn't wait. I . . ."

  "That's all right," he said, smiling. "Your father's doing fine."

  "God bless you, Doctor," the young man said, the tears coming into his eyes, but the young man smiling and shaking hands. "God bless you always."

  "That's all right."

  "Will you tell my mother now? It's been a long wait for her."

  "Certainly."

  The young man walked, hurrying, ahead of him to the lounge. Mrs. Scheller, in the dark blue dress and holding her handbag, was standing waiting for them, and when she saw them the tears started into her eyes, too.

  "But the doctor says he's fine, Mom," the son said. "He says he's all right."

  "That's right," he said, smiling and taking Mrs. Scheller's hand. "We got it all out, and he's in the recovery room now. Pretty soon they'll be bringing him back here to his own room."

  "May God bless you, Doctor," she was saving.

  "After they bring him back," he said, "you'll be able to see him for a few minutes. Of course, hell be pretty sleepy."

  "God bless you again, Doctor," Mrs. Scheller said, still crying and still holding his hand.

  "Thank you," he said. "He's going to be all right."

  So that's that, he was thinking, riding down in the elevator, and it's the way you always dreamed it would be and the way it is sometimes.

  You always did want to be a hero and when you win them it's great and it's impossible to even imagine anything else like it in this world.
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  In the surgeon's lounge he snapped off the light button next to his name and he walked to the door and out onto the street. He looked up at the sky, as gray as it had been in the morning, and he walked to his car.

  As he drove down the block, starting to relax, it came to him that he had had nothing to eat or drink since the coffee and the cake with Mary MacGowan almost six hours before and that he was hungry. With the heart at University and then the office he would not get another chance until they sat down at that party, and he would stop at the hot-dog cart near the river as he used to do regularly before the old man who ran it died during the summer from whatever it was.