by Robin Cook
"If s all here, Doctor, on the input/output sheet. It's been about 4,000 cc."
'Tour thousand!" I tried not to appear surprised, although it seemed a lot to me. "What has it been?"
"Well, mostly saline, but some Isolyte M, too," she answered.
What the hell was Isolyte M? I had never heard of it. Twisting the bottle that was running, I read "Isolyte M" and, twisting it the other way, "Sodium, chloride, potassium, magnesium…" No need to read farther; this was a maintenance solution. The input/output sheet was a jumble of seemingly random figures, but I liked that. Right from the beginning of medical school I had been fascinated by the balance of fluids and electrolytes, so fascinated that I could sometimes worry about the sodium and almost forget the patient. This patient's input seemed to match her output except for what had soaked into that huge dressing covering the wound. A sump suction had been set up to pull fluid from the bottom of her abdominal wound, but it didn't seem very effective. Also, the bland food she was getting probably didn't have much nutritional effect. It was delivered to her stomach by a tube through her nose; since her own digestive juices had formed a fistula, or passage, between the stomach and the colon, the food was actually going directly from the stomach to the large bowel and out the rectum essentially unchanged.
Although she did not appear to be dehydrated, her urine showed obvious evidence of infection, in the form of blood, bile, and small bits of organic matter floating around in the catheter bag. With so much crud in there, the only way to learn if her urine was too concentrated was to test its specific gravity.
"I don't suppose we have a hydrometer on the floor, do we?" The nurse disappeared, only too pleased to be given a task, regardless of its potential merit. I still had no way to explain Marsha's venous pressure. I continued to examine her, looking for some sign of cardiac failure to explain it and finding none at all. Apparently the inevitable was closing in: I would have to look at her wound. "Is this what you mean, Doctor?" The nurse handed me a bottle of papers designed to test urine for sugar.
"No, a hydrometer, a little instrument you float in the urine. It looks like a thermometer." She disappeared again while I looked at the label on the bottle she had given me. Perhaps I'd test the urine for sugar anyhow; no reason not to.
"Is this it, Doctor?"
"That’s the baby." I took the hydrometer and unhooked the catheter bag. Holding my breath to avoid the smell, I poured into a small vial what I guessed would be enough urine to float the hydrometer. Carefully I lowered the instrument into the urine, but I couldn't get a reading. The damn thing kept sticking to the side of the flask rather than floating free as it was supposed to. I held the flask in my left hand and tapped it with the knuckle of my right index finger, trying to free the instrument. I only succeeded in splashing urine on my arm. By adding more urine to the vial, I finally got the hydrometer to bob up and down. The specific gravity was within normal limits — in fact, was absolutely normal — so Marsha wasn't dehydrated. For some reason, medical people shy away from the word "normal" without its qualifiers; if s always "within normal limits" or "essentially normal."
Marsha groaned again. As I drew in a big breath, I was whacked by a symphony of smells in the room. As far back as I could remember, I'd never been able to cope with bad odors. In grammar school, when one of my classmates vomited I had been sure to follow with a sympathetic reflex once the smell reached me. In medical school, despite three masks and all sorts of mental tricks, I had been known to retch in the middle of pathology lab.
Still trying to think of an explanation for Marsha Potts's condition, I wondered if she might have Gram-negative bacteria in her blood stream, perhaps a bacterial infection like pseudomonas, for instance; pseudomonas sometimes leads to a condition called Gram-negative sepsis, which is one of medicine's most terrifying sights. One minute the patient is all right; then a shiver and everything goes to hell. Maybe that could explain the venous-pressure problem. But I saw no sign of sepsis.
Marsha was moaning regularly now, and each moan was like a new indictment passed down against me. Why couldn't I figure this out? Walking around to the other side of the bed, I directed the nurse's attention to the cockroach, which had moved a few feet, down to shoulder height. She jumped and vanished, returning almost instantly with several yards of toilet paper, which made quick work of the bug. A bug like that didn't bother me much — not like the rats in the hospital in New York. The grounds people there had always said they knew about them and were working on the problem, but I had seen them again and again.
Perhaps something was wrong with the three-way stopcock on the intravenous line. When I opened the stopcock to the position for measuring venous pressure, it didn't budge from zero. Flipping it closed again, I filled the column with the IV solution and then connected the column with the patient. The level stayed up for a few seconds before starting to fall rapidly, then slowly, as the nurse said it would, first to 10 cm. and finally to zero. Confusing, especially those three-way stop-cocks. I had never quite gotten them straight, never quite known which knob to turn for what connection.
I asked the nurse for a large syringe full of saline and unhooked the whole tangle of tubing from the catheter going into the femoral vein, just below the groin. Marsha had been sustained intravenously for so long that her arm veins were useless for IV's, and the doctors had begun using her leg veins. To my surprise, no blood from the vein came back up into the catheter tube, even with the pressure of the maintenance solution gone. When I flushed about 10 cc. of saline fluid through the catheter with the syringe, I felt a definite resistance; then suddenly the saline fluid went more easily. As I withdrew the plunger of the syringe, a red streak of blood appeared in the catheter.
Obviously there had been a plug at the end of the catheter inside Marsha's vein, probably a small blood clot, which had acted like a ball valve, allowing the IV maintenance solution to enter but keeping anything from coming back. A venous-pressure reading depended on blood being able to rise through the catheter. All this I told the nurse, but I didn't tell her that the blood clot was now probably in Marsha's lungs. If so, though, it had to be small, thank God.
Hooking up the column once more, I filled it and lined it up with the patient. After I was certain it showed a normal venous pressure and was going to stay there, I restarted the IV.
"I'm sorry, Doctor, I didn't know," the nurse said.
"No need to be sorry, no sweat." I was glad to have solved a problem, even a miniproblem. Considering that I had started with a blank mind, the achievement seemed notable, although the patient was the same. She moaned again, her lips twitching. She was just a shadow of a person, really, and my awareness of her erased the feeling of accomplishment. All I wanted to do now was get out of there, but it was not to be.
"Doctor, as long as you're here, would you mind looking at Mr. Roso? His hiccups are keeping the other patients awake."
As the nurse and I walked down the corridor toward Roso's ward, I thought what an unusual building the hospital was, something entirely new in my experience. Its halls communicated directly with the outside, at least in the old, low section, and grass grew right up to the edge of the hallway. A large monkeypod tree dominated the courtyard, leaning and rustling in the wind. The ground were immaculately manicured and studded with enormous tropical trees. What a difference from other hospitals I'd worked in. There had been one tree on the grounds of my medical school in New York, but it was cut down before I left. The rest was cement and brick, all yellow. But the wreck of them all was Bellevue, where I had done my fourth-year clinical clerkship (working essentially as an intern, although I was officially still a medical student). The halls there were covered with depressing brown paint, everywhere peeling away and so disgusting to touch that we had been careful to walk in the middle, away from the walls. My on-call room had a broken window and uncertain plumbing. It stood on the other side of the hospital from the medical wards, which could be reached only by navigating the respiratory center, w
here all the TB patients were. During the journey, I had sometimes unconsciously held my breath as I passed through the respiratory ward and so arrived breathless at my destination.
If Dante could have seen Bellevue, he would have given it a prominent place in the Inferno. How I had hated those two months. I saw a movie once that reminded me of Bellevue; it was Kafka's The Trial, and in it characters were forever moving down endless halls. That was Bellevue, endless halls, especially if you were holding your breath. Any window clean enough to see through revealed only another dirty building with more halls. Even an innocent act of nature could be dangerous. I once went into the men's room rather hurriedly, unzipping as I walked through the door, and literally fell into a group of patients who were busily mainlining heroin with hospital syringes. That was the first time patients threatened to kill me, but not the last.
Hawaii was nothing like Bellevue. Here I hadn't been threatened, not yet, anyway, and all the walls were clean and carefully painted, even in the cellar. I had supposed all hospital cellars looked alike, but here they were clean, even bright.
I don't know why TB worried me so much. Part of the irrational in all of us, I suppose, when you decide some things are bad and others won't affect you. After I read about malignant hypertension, I thought I had it every time I got a headache. Maybe TB bothered me because my first patient for physical diagnosis had had TB.
All of us medical students had been listening to each other's chests, which resulted in a lot of laughs and little instruction. Then we had been bussed out to a chronic-disease hospital to listen to patients for the first time. This place was called Goldwater Memorial, and it made Bellevue look like the Waldorf. After drawing a card with someone's name on it, I had approached the man's bed feeling so transparently new that I might have had a sign on my forehead reading "2nd Year Medical Student, 1st Attempt." Everything had gone fine until I listened to his left-costophrenic-angle area from the right side of the bed. Leaning across his chest, I had told him to cough, which he did, directly in my ear, and I could feel it dripping down the side of my head, all those drops of yellow phlegm teeming with antibiotic-resistant tuberculous organisms. Not even a shampoo in the men's room, using liquid soap from the dispenser, had made me feel right. When I got back to my apartment I had had to shampoo again and again, like Lady Macbeth.
So far, I hadn't had to deal with any of this hospital's TB patients. Maybe there weren't any in Hawaii.
My reverie ended. I looked at the nurse who was walking with me to see Roso. She was another of Hawaii's assets, very pretty, with a mixture of Chinese and Hawaiian blood, I guessed, a good slim figure, almond eyes, and beautiful teeth.
"Do you like to surf?" I asked, as we arrived at the door to the men's ward.
"I don't know how," she said softly.
"Do you live close to the hospital?"
"No, I live in Manoa Valley with my parents." That was unfortunate. I wanted to hear her talk, but we were nearing Roso's room.
"Has Roso been vomiting?"
"No, not at all, just hiccuping. I never thought hiccuping could be so bad. He's miserable."
Glancing at my watch before stepping into the ward, I saw it was going on midnight. Even so, I didn't mind seeing Roso. In many ways he was my favorite patient. Small night lights near the floor gave off a suffused glow that seemed to mix with the even sounds of breathing and snoring. Suddenly a sharp hiccup pierced the tranquility, and the snoring went out of phase. I could have found Roso in inky blackness by those hiccups. We had operated on him my second morning as an intern. Actually, "we" is not quite accurate: the chief resident and a second-year resident had done the operating while I stood and held the retractors for three hours. I was the first to admit my ineptitude in the operating room; and the way things were going, my ignorance was secure. Unlike a lot of medical students, who as a rule are eager for surgery, I was short on operating-room experience, mostly because I hadn't wanted it, but also because I had been more interested in the electrolytes and the fluid problems after the operation. This had suited everybody. The other med students didn't dig the chemistry, while I had trouble bringing myself to stand for six hours in the OR watching other people cut and sew. Especially after the scene that took place the second time I had "scrubbed" back in New York.
It was to be a cancer operation, a complete breast removal, or radical mastectomy, as it is called, by the Big Cheese, the World-famous Surgeon himself. Being only a second-year medical student at the time, I had had a lot of misgivings about it, and the fact that everybody seemed a little tense, even the residents, had added to my anxiety. Suddenly the Big Cheese had come striding into the operating room, regally splendid and late as usual. He had fingered a few instruments in the big sterilizer tray, picked the whole thing up, and crashed it to the floor, swearing that they were scratched and bent and totally unacceptable. The noise had scared the anesthesiologist so much that he jumped and knocked the mask right off the patient. I had disappeared, hoping I wouldn't be missed, which was indeed the case.
Eventually, of course, I began to stay through some operations, start to finish, but I have not to this day figured surgeons out. Another of them back there was such a quiet, pleasant fellow until he was in the operating room, where I once saw him hurl a clamp at the resident anesthesiologist because the patient moved. On another occasion, the same man ordered one of the surgical residents out of the OR, claiming he was breathing too heavily. At any rate, so far there hadn't been much incentive for me to spend time in the operating room, and I was pretty green at surgery when my internship started.
Despite my inexperience, I knew the scrub routine, how to wash my hands, holding them just so, how to dry them, and how to put on the gown and gloves; I could even tie a few surgical knots. This had been learned pretty much by trial and error. My first scrub, in third-year med school, had been for a suture job in the emergency-room OR. I had spent the usual ten minutes scrubbing my hands and forearms, and had cleaned my nails with an orange stick before awkwardly donning the gown. I had on the baggy pants, the hat, the mask, the whole works, and the nurse had finally helped me with the rubber gloves. After twenty-five minutes of concentrated effort, at last I was ready to go; my hands were as sterile as a moon rock. Then I had casually picked up a stool and walked over to the patient, thereby contaminating my hands, my gown, everything. The nurse and the resident had laughed hysterically; even the bewildered patient had joined in as I started over from the beginning.
In Roso's case, even from my limited vantage point behind the retractors, I had known that nothing about his ulcer operation was going smoothly. The chief resident kept cursing the poor protoplasm, and I had to agree that Roso's tissue bled easily. Some heavy bleeding started near the pancreas at the bottom of the hole, but the two of them managed to complete the Billroth I, which meant hooking up the stomach and intestine just about the same as they had been before the operation, although minus the ulcer. Then I was supposed to put in Roso's skin sutures. It was no big deal to anyone except me; for me it was everything. I thought about asking one of the residents to put his finger on my first throw of the knot, like tying a Christmas present. It seemed a funny thought for about a second.
Actually, for a procedure so simple, tying that knot had been aggravating as hell. Sutures are often very narrow and difficult to feel through rubber gloves, especially at the tips, where the rubber is thickest and where you need the most sensitivity. I knew I had to tie the knot so that the edges of the wound came together, just kissing, without tension and without causing the skin to roll under. I also felt everyone watching me, judging. Although I knew a lot of things, nothing mattered then except that knot, because the knot is the thing without which an operation falls apart quite literally.
The end of the black silk in my right hand disappeared in the skin on one side of the wound and emerged on the other. I brought it together with the other end of the silk strand, in my left hand, and laid the first throw, tightening it until the edges
touched lightly. Now for the next throw. But as soon as I let up on the tension, the wound popped open. I pulled it together again and put down the other throw as fast as I could, hoping somehow to beat the dehiscence — that gapping. The pitiful result left the edges of the wound dangerously far apart. Then, to my dismay, a hand reached out with scissors and cut the knot while partially suppressed giggles bubbled in the background.
Another hand began the suture again, dipping the curved needle easily under the skin to span the incision and come out the other side. I looked up in supplication to heaven; what good was I here when I couldn't even tie a knot?
I had gotten another chance on Roso's second row of stitches, which went in the opposite direction. By the time the second throw went down, the suture was so tight that the skin was bunched up in little ripples and the edges were rolled under from the tension. Out came the scissors again, courtesy of the second-year resident who had snipped through my first knot, and the wound separated with relief. It looked so easy and rhythmical when someone else did it. I had detected a trick here and there, though, a twist after the first throw, for instance. Instead of leaving the suture flat on the first throw, you pulled it back, both strings toward you. But that was only half of it. I tried again, with a little better result, although it was still too tight. At least Roso had been finished, for the time being.
The first suggestion of trouble was the hiccups, which had started about three days after the operation. Coming regularly every eighteen seconds, they were amusing at first. In fact, Roso became a hospital curiosity with his funny, clockwork hiccups. He was only fifty-five, but years in the pineapple fields made him look much older, all stooped and skinny; his pants kept falling off as he plodded through the ward pushing his IV stand. He, too, had run out of arm veins for his IV's and, like Marsha, had a catheter in his right groin. This caused even more trouble. If he tightened the drawstring enough to keep his pants on, his IV stopped. So he had to walk with one hand on the IV pole, the other holding up his pants.