The Sisterhood

by Michael Palmer

  David ordered Butterworth’s right foot placed in a clear, plastic bag to keep it visible without contaminating his operative field. The foot was the color of white marble.

  Using small injections, he deadened an area of the man’s right groin. With no pulse to guide him, he knew that the femoral artery could be an inch or more away from his incision. A miscalculation, and he faced an operation so difficult that a second incision might be the only solution. Focus in, he thought. See it. Hidden beneath his mask, the corners of his mouth turned up in a thin, knowing smile. He was ready.

  “Scalpel, please,” he said, taking the instrument from the scrub nurse. He paused, closed his eyes, and breathed in the electricity of the moment. Then he opened them and surveyed the expectant faces watching him, waiting for him. With a slight nod to the anesthesiologist and a final glance at Butterworth’s bloodless foot, he made his incision. The taut skin parted, immediately exposing the femoral artery. “Bull’s-eye,” he whispered.

  In minutes the artery, stiff and heavy with clot, was isolated and controlled with two thin strips of cloth tape placed two inches apart. David made a small incision in the vessel wall between the tapes. Gently he eased a long, thin tube with a deflated balloon at the tip down the inside of the artery toward the foot. When he determined that the tip was in position, he blew up the balloon and carefully drew it back through the incision. Two feet of stringy, dark clot pushed out before David lifted the balloon free. Repeating the procedure in the opposite direction, he removed the thicker clot that had caused the obstruction in the first place. An irrigation with blood thinner, and he was ready to close. He tightened the cloth tapes to prevent blood flow through the artery, then closed his incision in the vessel with a series of tiny sutures.

  For the second time in less than twenty minutes David shared a momentary gaze with each person in the room. He then took a silent, deep breath, held it, and released the tapes. Instantly, Butterworth’s foot flushed with life-giving color. A cheer burst out from the team. Textbook perfect. The whole case, textbook perfect. In absolute exhilaration, he called out the good news to Butterworth, who had slept through the entire procedure.

  “That was really fine work, Dr. Shelton. That was really fine work, Dr. Shelton. That was really fine work, Dr. Shelton.” David repeated the words of the veteran scrub nurse over and over, trying to reproduce her inflection exactly. “Maybe you should give her a call and ask her to say it again so you can get it just right,” he advised himself. He had dictated an operative note, showered, and dressed. Now he was headed down the corridor of Four South to share the news of Butterworth’s successful operation with Dr. Armstrong.

  He glanced at his watch. Ten of eight. His second straight late evening in the hospital. A first for him since joining the surgical staff more than eighteen months before.

  Margaret Armstrong had already arrived on the floor and was seated at the nurses’ station sharing coffee and relaxed conversation with Christine Beall and the charge nurse, Winnie Edgerly. As David approached the group, his eyes were drawn to Christine. Her eyes and her smile seemed to be saying a thousand different things to him at the same time. Or maybe they were his words, his thoughts, not hers. Lauren’s jewel-perfect face flashed in his mind, but faded as the tawny eyes tightened their hold.

  Dr. Armstrong’s voice pulled him free. “Yo, David,” she called out merrily. “Word is sweeping the hospital about my little man’s new foot. Bravo to you. Come, we shall toast your successful operation with a cup of this coffee.” She glanced in her cup, grimaced, then added, “If, in fact, that is what this is.”

  She wore a black skirt and light blue cashmere sweater. A simple gold butterfly pin was her only jewelry. Her white clinic coat, unbuttoned, was knee length-the type reserved unofficially only for professors or those with sufficient seniority in the teaching community. Her dark wavy hair was cut short in a style perfect for her bright blue eyes and finely carved features. There was an air about her, an energy, that commanded immediate attention and respect. An article written six years before about her contributions to her field had dubbed her the Grande Dame of American Cardiology; she had been only fifty-eight years old at the time.

  As David took in the scene at the nurses’ station, he couldn’t help but reflect on the easy, animated relationship that existed between Armstrong and the two nurses. Quite the opposite from Dr. Wallace Huttner, even allowing for the fact that Dr. Armstrong was a woman. The contrast became even more striking when she got up and poured him a cup of coffee.

  She introduced him to the nurses as the “hero of the day,” and, with a mischievous wink at Christine, added that David was, to the best of her knowledge, single. He blushed and covered his eyes in genuine embarrassment, but realized at the same time that he was carefully avoiding any further eye contact with Christine. Seconds later, Armstrong had him describing Butterworth’s operation in detail. For the moment the danger had passed.

  Rona Gold, a practical nurse, joined the group as David used red and blue pens to sketch pictures of the procedure he had done.

  It seemed clear to David that Armstrong already knew the details, probably from one of the O.R. nurses. Still, she encouraged him at every chance to continue.

  “Well,” she said finally, “I stopped by the recovery room to see Aldous and he doesn’t remember a thing. Snoozed his way through the whole ordeal. Here he is in danger of losing a leg or worse and he sleeps through the procedure. That is my idea of good local anesthesia, what?”

  “I think I put him to sleep while I was trying to explain what I was going to do to him,” David said.

  Armstrong shared an appreciative laugh with the three nurses, then said, “David, you mentioned something about having a complicated patient here on four South. Charlotte Thomas?”

  “Why, as a matter of fact, yes,” David said. “Are you a mind reader as well as a cardiologist?”

  “Nothing that exotic. The nurses and I deduced that she was the only one on the floor who fit the bill, so I took the chance and went over her chart.”

  “And?”

  “And you’re right. She is rapidly developing total body failure. In fact, I have only one observation to add to the excellent note you wrote this morning outlining her many problems. Your Mrs. Thomas has, on top of everything else, definite signs of coronary artery disease on her electrocardiogram. At least, in my interpretation of her electrocardiogram,” she added modestly. “I really have nothing dramatic to contribute to what is already being done. Does it seem as though the bowel obstruction will require reexploration?”

  “God, I hope not,” David said. “It would mean her third major operation in less than three weeks.”

  “Dr. Shelton, I have a question,” Christine said.

  He responded quickly. “It’s five, five, five-two, oh, one, six.”

  “What is?”

  “My phone number!” David said, immediately realizing that he should have learned more about Christine Beall before exposing her to his sense of humor.

  Gold and Edgerly laughed briefly, but Christine did not crack the slightest smile. “That’s not funny,” she said. “Neither is a woman as sick and in as much pain as Charlotte Thomas.”

  David muttered an apology, but she ignored it.

  “What concerns me,” Christine continued, “is why, if she has so many seemingly incurable problems, Dr. Huttner has made her a full Code Ninety-nine. Espe daily after what happened last night.”

  “Last night?” Armstrong asked. “What happened last night?”

  David paused, uncertain which of them she was addressing. Christine sat back, looking expectantly at him for his version.

  “Well,” he said finally, “Mrs. Thomas’s husband and Dr. Huttner got into a discussion about the aggressive approach Huttner has elected to take in her treatment. The husband was frustrated and more than a little angry. Understandable, I guess, and certainly something we’re all used to encountering.”

  “How did Wally handl
e it?” Armstrong leaned forward with interest, absently rolling her coffee cup back and forth between her hands.

  “As well as could be expected under the circumstances, I think,” David said. “He may have overreacted a bit. He stuck by his philosophical guns. Refused to alter his treatment plan regardless of what Thomas, who was under obvious strain and pressure, demanded him to do. Finally Huttner drew me into the whole thing. I’m afraid that my opinion and the way I expressed it were not quite what he wanted to hear in that situation.” David managed a rueful grin at his own understatement.

  “And how do you feel about the whole thing, David?”

  Dr. Armstrong’s voice was soft. There was an openness in her expression that made him certain there would be no recrimination from her.

  “I think it’s a bitch of a situation, if you’ll pardon the expression,” he said. “I mean it’s always harder to decide not to use treatment on a patient than it is to just go ahead and employ every medicine, machine, and Operation you can think of. That’s why we end up with so many patients who drag on as little more than vegetables.

  “Personally,” he continued, “having watched several of my own family members die prolonged, painful deaths, I think there are times when a doctor must make the decision to hold off and let nature take its course. Don’t you agree?”

  Hold off … Let nature take its course.… There was something about the words, the way they were said. Margaret Armstrong closed her eyes as they echoed in her mind, then yielded to other words. Other words and the voice of a young girl.

  “It’s all right, Mama.… I’m here, Mama.”

  “Don’t you agree, Dr. Armstrong?”

  “Mama, tell me what I can do to help.… Does it still hurt as much? Tell me what I can do to help.… Please, tell me what I can do.…”

  “Dr. Armstrong?”

  “Oh, yes,” she said. “Well, David, I’m afraid I agree much more with Dr. Huttner’s approach than with yours.” How long had she drifted off? Were they expecting an explanation?

  “How do you mean?”

  No, she decided. No explanations. “The way I see it, following your philosophy, a physician would constantly be confronted with the need to play God. To decide who is to live and who is to die. A medical Nero. Thumbs up, we put in an intravenous. Thumbs down, we don’t.”

  David responded with an emotion and forcefulness that momentarily startled even him. “I believe that the major responsibility of a physician is not constantly to do battle against death, but to do what he can to lessen pain and improve the quality of patients’ lives. I mean,” he went on, less vehemently now, “should every treatment, every operation possible be used on every patient, even though we know there’s only a one-in-a-million or even a one-in-ten-thousand chance that it will help?” In the silence that followed, he sensed that once again he’d used a verbal cannon where a slingshot or perhaps even a velvet glove had been called for.

  At this point, Winnie Edgerly, a straightforward if somewhat plodding woman of about fifty, felt moved to enter the discussion. “I cast my vote with Dr. Armstrong,” she said earnestly. “I wouldn’t want any tubes pulled out of me if there was even the slightest chance. I mean, who knows what might happen or what might come along at the last minute to help. Right?”

  “Now don’t get me wrong, Mrs. Edgerly,” David said, carefully minimizing the intensity in his voice. “I am not advocating pulling out any tubes from anyone. I’m arguing that we should all think twice—or more than twice—before putting the tubes down someone in the first place. Sure they can help, but they also can prolong hopeless agony. Does that help make my feelings any clearer?”

  Edgerly nodded, but her expression suggested that she did not agree.

  Finally Dr. Armstrong said, “So, David, how does all this apply to your Mrs. Thomas?”

  “It doesn’t,” he said shortly. “The treatment program for Mrs. Thomas has been clearly spelled out by Dr. Huttner. It’s my responsibility to carry those plans out to the best of my ability. That’s all there is to that.”

  Armstrong seemed about to say something further when the overhead page sounded, summoning David to the emergency ward. “When it rains, it pours.” He smiled expectantly at Dr. Armstrong.

  “But I’ll bet you don’t mind getting wet like this at all,” she said. “I’m very happy for you, David.”

  “Thank you, Dr. Armstrong.” He swallowed the last of his coffee. “Thank you for everything.”

  With a nod to Edgerly and Gold, and a longer look at Christine, David headed off toward the emergency ward.

  Christine sat silently behind the nurses’ station as the others dispersed to go about their business. There was a puzzled, ironic expression on her face. She slipped her right hand into the pocket of her sweater and, for a minute or two, fingered the syringe and ampule of morphine that she had wrapped in a handkerchief and stuffed inside. Then she rose and walked with forced nonchalance down the hall toward Room 412.

  CHAPTER IX

  “Do you do hands, Dr. Shelton?” Harry Weiss, the hawk-nosed resident who had called David to the emergency ward, could easily have won the role of Ichabod Crane in a production of The Legend of Sleepy Hollow.

  “Show me what you have,” David said.

  The emergency ward was in its usual state of mid-evening chaos. Two dozen patients in various stages of discomfort and anger at the hospital sat in the crowded waiting room. Litters glided past like freighters in a busy port, bearing their human cargo to X ray or the short-term observation ward or an in-patient room. Telephones jangled. A dozen different conversations competed with one another. David caught snatches of several of them as the resident led him to Trauma Room 8. “What do you mean you can’t have the results for an hour? This man is bleeding out. We need them now …” “Mrs. Ramirez, I understand how you feel, but I can’t help you. There is simply no Juan Ramirez on the emergency ward at this time …” “Now, you’re going to feel a little pinprick …”

  The patient David had been called about was a forty- year-old laborer who had lost a brief but unmistakably furious encounter with his power saw. The top halves of two fingers were gone completely, and a third was held together at the first knuckle by a sliver of tendon. Another no-win situation, David thought to himself as he evaluated the damaged hand. He spoke briefly with the man, who had stopped his profuse sweating but was still the color of sun-bleached bone. Then he guided the overwrought young resident into the hallway. It was David’s decision whether to do the repair himself or to spend the extra time to take the resident through it. He chose to take the time, remembering the many late nights when other surgeons had made the extra effort to teach him. It was nearly half an hour before he felt confident that Weiss could complete the repair on his own.

  Four South was unusually quiet as David stepped off the elevator and started down the corridor toward Room 412. A burst of laughter from the nurses’ lounge suggested that it was coffee break time—at least for some of the staff. He thought about Christine Beall, half hoping that she might step out of one of the rooms as he was passing.

  Just the image was enough to rekindle an uneasy warmth. So, she’s interesting looking and has strange eyes, David thought. Lauren is beautiful and has incredible eyes. You’re reacting like this because she’s away, that’s all. Face it, with Lauren you have everything you’ve ever wanted in a woman—beauty, brains, independence. Right? Right. The logic was all there, black and white and irrefutable. But somewhere in the back of his mind a small voice was saying, “Think again … think again …”

  The lights in Charlotte Thomas’s room were off. David stood at the doorway, staring across the darkness toward her bed. The gastrointestinal drainage machine, set for intermittent suction, whirred, stopped, then reassuringly whirred again. Bubbles of oxygen tinkled through the water of the safety bottle on the wall. He debated whether or not to disrupt her sleep in order to check findings he knew would be unchanged at best. Finally he stepped across the ro
om and turned on the fluorescent light over her bed.

  Charlotte was lying on her back, a tranquil half-smile on her face. It took David several seconds to realize that she was not breathing.

  Instinctively, he reached across her neck and checked for a carotid pulse. For an instant he thought he felt one, but then knew that it was his own heart, pounding through his fingertips. With both fists he delivered a sharp blow to the center of Charlotte’s chest. Then he gave two deep mouth-to-mouth breaths and several quick compressions to her breastbone. Another carotid check showed nothing still.

  He raced to the doorway. “Code Ninety-nine four-twelve,” he screamed down the deserted corridor. “Code Ninety-nine four-twelve.” He ran back inside and resumed his one-man resuscitation.

  Thirty seconds passed in what seemed like a year before Winnie Edgerly burst into the room pushing the emergency crash cart. At the same instant the page operator, alerted from the nurses’ station, announced, “Code Ninety-nine, Four South. Code Ninety-nine, Four South. Code Ninety-nine, Four South.”

  Seconds later, Room 412 began to fill with people and machines. Edgerly inserted a short oral airway into Charlotte’s mouth and began providing respirations as best she could with a breathing bag. David continued the external cardiac compression. An aide rushed in, then wandered meekly to one side of the room, waiting for someone to tell her what to do. Two more nurses raced in, followed by Christine, pushing an electrocardiograph machine. Leads from the machine were strapped tightly to Charlotte’s wrists and ankles.

  A resident appeared, then another, and finally the anesthesiologist, a huge Oriental who introduced himself as Dr. Kim. He replaced Edgerly at the head of the bed and looked over at David, who had turned the job of cardiac massage over to one of the residents and had moved to man the cardiograph.