The Sisterhood

by Michael Palmer

  “It’s all right to do anything, dear. We’ll be able to figure things out. Now just relax and give me what other information you have.”

  The woman’s first warm words had an immediate effect. Christine took a deep breath and felt much of her tension vanish. “Thank you,” she said softly. Evelyn’s reassurance had reminded her: she was not functioning in isolation. She was part of a team, a movement committed to the highest good. If her role was difficult, at times frightening, so were those of the rest of her sisters. For the first time a note of calm appeared in her voice. “What I left out was that shortly after her surgery she had to be operated on again for drainage of an extensive pelvic abscess. One week ago she developed pneumonia, and last night a nasogastric tube was inserted because of the possibility of an intestinal obstruction.”

  She was still shaking, but now the words came more easily.

  “Recently she developed a large, painful sacral pressure sore and is now requiring around-the-clock Demerol as well as the usual local therapies. The physician’s notes in her chart as of yesterday state that her pneumonia is worsening. Despite all her problems, she has been designated a full resuscitation should she arrest.” Almost done, she thought. Thank God. “Mrs. Thomas is married, has two children and several grandchildren. That is the end of my presentation.” She sighed deeply.

  “Miss Beall,” Evelyn asked, “could you please tell me if there is documented evidence in her record of the spread of her tumor to other organs?”

  “Oh, yes, I’m sorry. I missed part of a page. There was one thing. An X-ray report. It’s a liver scan dated last week. The report from the radiologist says, ‘Multiple filling defects consistent with tumor.’ ”

  “When was the last case that you handled?”

  “The only case. Nearly a year ago. Mrs. Thomas would be my second.” It wasn’t like this the last time, she thought. That was beautiful, not an ordeal. Her legs felt boneless. Instinctively she looked about for a chair.

  “Thank you for your call,” Evelyn said, “and for your excellent case presentation. The Sisterhood of Life Regional Screening Committee will evaluate this patient and contact you within twenty-four hours. In the meantime, as you know, you are to take no action on your own.”

  “I understand.” It was almost over.

  “Oh, one more thing, Miss Beall,” Evelyn added. “The name of this patient’s physician?”

  “Her physician?”

  “Yes.”

  “It’s Dr. Huttner. Wallace Huttner, the chief of surgery here.”

  “Thank you,” Evelyn said. “We’ll be in touch.”

  CHAPTER III

  David Shelton drummed impatiently on the arm of his chair and leafed through a three-month-old issue of The American Journal of Surgery. His excitement and anticipation at making evening rounds with Wallace Huttner had been dulled by a wait that had now grown to nearly three quarters of an hour. Huttner must have encountered unexpected difficulty in the operating room.

  For a time David paced through the deserted surgeons’ lounge, closing locker doors—a gesture that seemed, inexplicably, to restore some order to the situation. Forty-five minutes in an empty locker room had hardly been part of his scenario for the evening.

  With mounting concern that Huttner might have forgotten their appointment altogether, he took off the suit he had resurrected from the recesses of his closet for the occasion and changed into a set of scrub greens, then slipped paper shoe covers over his scuffed loafers and tucked the black electrical grounding strip in at the back. He considered putting on his own green canvas O.R. shoes, but rejected the notion, fearing that the shoes, a clean, new pair, might give the impression, however accurate, that he had not spent much time in the operating room of late.

  The ritual of dressing for the O.R. had an immediate buoying effect on his flagging morale. Donning a paper mask and hair guard, he began absently humming the opening bars of “La Virgen de Macarena,” a melody he had first heard years before, heralding the arrival of the matador at a Mexico City bullfight.

  Suddenly he realized what he was singing and laughed out loud. “Shelton, you are really off the wall. Next thing you’ll do is demand two ears and a tail for a successful appendectomy.” Stopping before a mirror, he stuffed several protruding tufts under his cap, then stepped onto the surgical floor.

  The Dickenson Surgical Suite, named after the first chief of surgery at the hospital, consisted of twenty-six rooms, devoid of windows, and occupied the entire seventh and eighth floors of the East building. Ubiquitous wall clocks provided the only hint of what life might be doing outside the hospital. In atmosphere, politics, social order, even language, the surgical suite was a world within a world within a world.

  From his earliest days as a medical student, and even before, David had dreamed of being a part of that world. He loved the sounds of machines and hushed voices echoing down the gleaming hallways, the tension in hours of meticulous surgery, the seconds of frantic action in a life-or-death crisis. Now, for the second time in his life, the dream was becoming reality.

  Scanning the lime-tiled corridor, he saw signs of activity in only two of the operating rooms. The others had been scrubbed down and set up for the first cases of the next morning, then darkened for the night.

  He bet himself that Huttner would be working in the room on the right and lost a weekend in Acapulco with Meryl Streep.

  “Can I help you?” The circulating nurse met David at the doorway. She wore a wraparound green scrub dress that fell short of concealing her linebacker’s build. Turquoise eyes appraised him from between a paper mask and a cloth, flower-print hair cover.

  Assert yourself, David thought. Show some nice, crisp consternation at not being recognized. He was trying to formulate an intimidating response when Huttner looked over from his place at the right side of the table.

  “Ah, David, welcome,” he called out. “Edna, that’s Dr. Shelton. Will you get him a riser, please. Put it, ah … over there behind Dr. Brewster.” He nodded toward the resident who was assisting from across the table.

  David stepped onto the riser and looked down into the incision.

  “Started as a simple oversew of a bleeding ulcer,” Huttner explained, unaware—or, at least, not acknowledging—that he was late for their rounds. “We encountered a little trouble when we got in, though, and I decided to go ahead with a hemigastrectomy and Bilroth anastomosis.” David took note of Huttner’s choice of pronouns and filed the insight away in the back of his mind.

  Within a few seconds the rhythm in the room, disrupted by David’s arrival, was reestablished. It became rapidly apparent to him that Huttner’s concentration, deftness, and control were extraordinary. No wasted words or motion. No outward evidence of indecisiveness. Although others in the room were playing their parts, he was clearly both conductor and principal soloist.

  Suddenly a pair of scissors slipped off the side of Huttner’s hand as the scrub nurse passed them to him. They hit the floor with a clatter that might have been a small explosion. The surgeon’s gray-blue eyes flashed. “Goddammit, Jeannie,” he snapped, “will you pay attention!”

  The nurse stiffened, then muttered an apology and carefully handed over another pair. David’s eyes narrowed a fraction. From his vantage point the pass had seemed quite adequate. He glanced at the wall clock. Seven thirty. Huttner, he realized, had probably been operating for the better part of twelve straight hours.

  A minute later, Huttner surveyed his results then rotated his head to relieve the tightness in his neck. “Okay, Rick, she’s all yours. Go ahead and close,” he said to the resident. “Standard post-op orders. I don’t think she’ll need the unit, but use your judgment when she’s ready to come out of the recovery room. If there are any problems, contact Dr. Shelton. He’ll be covering for me while I’m down at the vascular conference on the Cape. Any questions?”

  David thought he saw a flicker of heightened respect and interest appear in the eyes of the scrub nurse. Rea
l or imagined, the look immediately rekindled his excitement about what the next three days held in store for him.

  Huttner stepped back from the table, stripping off his bloodstained gown and gloves in a single motion, and headed for the lounge with David close behind. Rather than collapsing in the nearest easy chair, as David expected, Huttner walked casually to his locker, withdrawing his pipe and tobacco pouch. He filled, packed, and lit the elegant meerschaum before settling into a thick leather couch. With a wave of his pipe, he motioned David to join him on the sofa.

  “Turnbull should have referred that woman for surgery two days ago,” he said, commenting on the internist who had failed to stop the bleeding ulcer. “I’ll bet I wouldn’t have had to take her stomach if he had.” Huttner closed his eyes and massaged the bridge of his nose with carefully manicured, porcelain fingers.

  In his early sixties, a tall, angular man an inch or two over six feet with dark hair appropriately gray at the temples, Huttner appeared every bit the patrician depicted by his press clippings.

  “I’ve been hearing some nice things about your work from the nurses in the O.R., David,” Huttner said in his well-cultivated New England accent.

  Nice things. David spent several seconds evaluating the compliment. It was a reflex reaction, born of nearly eight years of condescending interviewers and pseudo-solicitous colleagues. David disliked the trait, but had come to expect it. Huttner’s flattery was genuine, he was sure.

  “Thanks,” he said. “As you saw tonight, some of them don’t even know me yet. I mean, one major case every week or two is hardly the best basis for judging.” His words were not bitter—merely a statement of fact. David knew that Huttner might perform fifteen or more major operations for each one of his own.

  “Patience, David, patience,” Huttner said. “I recall telling you that when you first came to see me about applying for staff privileges. You must remember that, just as physicians are constantly hoisted up on pedestals, so are they also under continuous, magnified scrutiny.” He tapped his fingertips together, carefully selecting his words. “Problems such as … ah … have befallen you are not quickly forgotten by the medical community. They are a threat, pointing up a vulnerability that most doctors don’t want to admit they have. Just keep doing good, conscientious work the way you have been, and the cases will come.” He sat back pontifically and folded his hands around the meerschaum.

  “I hope so,” David said, his smile a bit forced. “I want you to know how grateful I am for your trust and acceptance. It really means a lot to me personally.”

  Huttner brushed the compliment off with his pipe, although his expression suggested that it was expected and would have been missed. “Nonsense, I’m the one who is grateful. It’s a relief to know that my patients will have a bright young Turk like you looking after them while I’m gone. As I recall, you trained at White Memorial, didn’t you?”

  “Yes, sir, I was chief resident there once upon a time.”

  “I never could seem to get accepted into that program,” Huttner said, shaking his head in what might have been wistfulness. “And it’s ‘Wally.’ I get enough ‘sirs’ every day to fill King Arthur’s Court.”

  David nodded, smiled, and stopped himself at the last possible instant from saying, “Yes, sir.”

  Huttner bounced to his feet. “A quick shower, then I’ll sign out to you on the floors.” He tossed his scrub suit into a canvas hamper, then took a journal from his locker and handed it to David. “Take a look at this article of mine on radical surgery for metastatic breast disease. I’ll be interested in what you think.”

  With that, he strode into the shower room, calling out just before he turned on the water, “You play tennis, David? We have to get together and hit a few before the weather closes in on us.”

  “It’s often hard to distinguish between my tennis and my weight lifting,” David said softly enough to be certain Huttner couldn’t possibly have heard. He thumbed through the article. Printed in a rather obscure journal, it advocated radical breast, ovarian, and adrenal surgery for patients with widespread breast cancer. The concept was nothing revolutionary. In certain instances it was accepted. However, as horrible as the disease was, seeing the radical surgical approach laid out in print, scanning the tables of survival, brought a tinge of acid to David’s throat. Survival. Was that really the bottom line? He slapped the journal shut and shoved it back in Huttner’s locker.

  The page operator was announcing the eight o’clock end to visiting hours when the two surgeons started making rounds on the floors in the West building. Earlier David had seen the patients he had in the hospital—a ten-year-old boy in for repair of a hernia and Edwina Burroughs, a forty-year-old woman whose factory job and four pregnancies had given her severe varicose veins, gnarled and twisted as the roots of a Banyan tree.

  Wallace Huttner had more than twenty-five patients scattered over three different buildings. Almost all of them were recovering from major surgery. On every floor Huttner’s arrival had immediate impact. Horseplay around the nurses’ station stopped. Voices lowered. The charge nurse materialized, charts in hand, to accompany them on their rounds. Replies to Huttner’s occasional questions were either stammered monosyllables or nervous outpourings of excess information. Throughout Huttner maintained an urbane politeness, moving briskly from one bedside to the next without so much as a hint of the fatigue David knew he must be feeling. The man was absolutely one of a kind, he acknowledged to himself. A phenomenon.

  Before long, a comfortable pattern had evolved to their rounds. Huttner allowed the charge nurse to lead them to the doorway of a room. Then he took the patient’s chart from her and proceeded to the bedside. David, the charge nurse, and often the staff nurse on the case followed. Next, Huttner handed the unopened chart to David, introduced him to the patient, and gave a capsule history of the initial problem, operative procedure, and subsequent course of treatment, couching details in medical jargon that no one except a physician or nurse could possibly have understood.

  Finally he conducted a brief physical examination while David flipped through the record, using a spiral-bound pad to record pertinent lab data as well as Huttner’s overall approach and plan for the case. For the most part, he tried to remain inconspicuous, speaking when addressed, but keeping his questions to what seemed like an intelligent minimum.

  From time to time he glanced at Huttner. As far as he could tell, the man seemed satisfied that his charges were being left in capable hands. Before long, though, David began feeling uneasy. Despite the legends, the backup residents, and the unquestionable—perhaps unparalleled—surgical skills, Wallace Huttner was sloppy: progress notes were brief and often lacking some piece of information; some abnormal laboratory results went undetected for several days before they were noticed and a recheck ordered. Small things. Subtle things. But the pattern was there, unmistakable. It was not the kind of carelessness that would affect every case, but inevitably it would be manifest somewhere—in a prolonged hospital stay, a second operation, even a death.

  He must know, David thought to himself. He knows, but so far he just hasn’t found any way of dealing with the problems. It wasn’t lack of pride or caring or skill—Huttner clearly possessed all three. The man was simply spread too thin, David decided. Too many cases. Too many committees, panels, and teaching obligations. How much could a man do in one day? Sooner or later he must either draw lines or make compromises or … get help. Maybe Lauren was right, he realized excitedly. Maybe Huttner was looking for a partner. Or maybe, David laughed to himself, Huttner had chosen him to cover the practice believing that of all the surgeons in the hospital he was the least likely to notice these inadequacies. No matter. The oversights and omissions were small ones. He would go through the charts the next day and fix it all up.

  Just keep your mouth shut, he told himself. Only a few cases to go, then you’re on your own.

  Minutes later, David’s decision to keep silent was challenged. The patient was a
man in his late fifties, a commercial fisherman named Anton Merchado. He had been admitted to the hospital several weeks earlier for an abdominal mass. Huttner had drained and excised a cyst on the pancreas and Merchado was recovering nicely when he developed symptoms of an upper respiratory infection. In a telephoned order, Huttner had put the man on tetracycline, a widely used antibiotic.

  The condition must have improved, David thought, because there was no further mention of it in Huttner’s brief notes. However, the tetracycline order had never been rescinded. It had been in effect for nearly two weeks.

  Anxious to speed up rounds, Huttner was giving his capsule review of the man’s history while he examined his heart, lungs, and abdomen. David stood off to one side, his attention focused more on the chart than on what the older surgeon was saying.

  On the day before Merchado was to be discharged from the hospital, he had developed severe diarrhea. Huttner’s initial impression was viral enteritis, but over a few days the condition worsened beyond what a simple viral infection would cause. The early signs of dehydration began to appear.

  David flipped from the progress notes to the laboratory reports and back. Huttner’s mounting concern was mirrored each day in an increasing number of orders for laboratory tests and diagnostic procedures, all unrevealing. Efforts intensified to keep pace with Merchado’s deteriorating condition, but there could be no doubt that the man was on a downhill slide.

  As David read, the germ of an idea took root. He scanned page after page of laboratory reports, looking for the results of the stool cultures that had been ordered on several successive days.

  “Well, what do you think?” Huttner said, turning to David. “David? …”

  “Oh, sorry.” David looked up. “I noticed the man was still on tetracycline and was just looking to see if he might have somehow developed staph colitis secondary to the treatment. It doesn’t happen often, but …”