by Robin Cook
The knife slipped through her skin with zero resistance. She was a little edematous on the foot, so that clear fluid rather than blood began to run from the wound. I was lucky to find the vein right away, and lucky I hadn't accidentally cut it. After making a little nick in the wall of the vein, I slid the catheter easily inside it, first try, as drops of sweat appeared on my forehead from the heat of the bright light. Using silk, I tied the catheter in place and closed the little wound, watching the IV run freely. With my foot I pushed the tray away, snapped off the gloves, and walked rapidly out toward the sunlight and the birds.
Washing my hands, I felt a deep disgust with myself, and I didn't know exactly why. She was a human being; I was supposed to help her. But the situation and her condition revolted me so much I had trouble accepting the responsibility. Where was my compassion; where was it going?
My first scrub was at eight, a cholecystectomy, or gall-bladder removal, with a private surgeon. My patient, Mrs. Takura, was scheduled for another operating room, to follow a ganglion removal; her operation should begin about nine, barring complications with the ganglion. Obviously I was going to be late for Mrs. Takura, but that was typical. The intern is a kind of pawn in the medical game; he is the first line of defense, sacrificed without remorse, disposable in the end, but needed, it seems, in the middle.
I pushed into the surgeons' locker room and began to put on a pale green scrub suit. It was so cramped in there that everybody always got shoved around a little, in a good-natured way. In fact, the sense of equality and the recognition of everybody as a person made scrubbing there a pleasure. Back in med school, the students and house staff had dressed in a completely different area set off by doors and a separate stairway from the sanctum sanctorum of the attendings' dressing quarters. It was almost as though a surgeon's image would crumble if you saw him in nature's state.
One med-school attending was so nasty that students actually shook while presenting their cases. A friend of mine — an excellent doctor, though inclined to stage fright — once had a complete lapse of memory at a bedside as he started to run through the facts in front of this attending. I knew he had the case down cold, but he could not get it out. "This woman presents an… uh… uh…" His face flushed and his pulses hammered at the sides of his neck. The attending could have eased the situation by suggesting that we come back to the case later, or even by giving a key word from the chart to bump the student's memory chain. Not a chance. He had flown into a rage, shouting in wonderment that a person so stupid could have gotten into medical school and ordering the student out of his sight until he knew his patients well enough to present them. Not all the attendings were like that, but a significant number were, even, sometimes, the chief of the service. Naturally, after one of those episodes, rapport between student and patient was in bad repair when it came time to draw blood the following morning. As time goes on, many details of medical school will blend and merge into generality, but not, I think, the scenes of rant and frenzy staged by overbearing surgeons. Some of them behaved so violently that it almost seemed as if they hated medical students; and yet these men were our mentors, our teachers and models.
After the green gown, I put on canvas boots and plodded down the long surgical corridor. Some of the OK doors were closed, and as I passed their small windows I could glimpse Ku Klux Klan-like groups clustered in the center of the room. Other doors were open, some with cases going on, others empty with anticipation. Dozens of nurses moved about, highly organized and busy, many of them looking quite pretty — a high achievement for anyone in one of those shapeless suits, with her hair tucked under a scrub hat. Others, however, might have done well at defensive tackle for the New York Giants, playing without equipment and just scaring the opponent into submission. Everybody said good morning; it was a friendly place.
When I moved up to the sink to scrub for the gallbladder operation, the surgeon and a resident were already there. The resident was Oriental, small, silent, and respectful. I smiled to myself, thinking of my friend Carno's description of the resident as being so small he had to run around in the shower to get wet. The smile started an itch under my mask. Uncanny how that always happened. Always after scrubbing came the itch, usually along the side of my nose or at the corner of my forehead. Of course, I couldn't scratch it until the operation was over and we broke scrub. Twisting my face and wrinkling my forehead occasionally brought minor relief. But the itch remained, fluctuating with my degree of concentration on what I was doing. For me, it was the most annoying part of the OR — aside from the retractors.
"Your name's Peters, huh? Where you from?
Where'd you go to school? Oh, one of the big boys from back east, huh?"
There it was, reverse prejudice. It seemed crazy now that one of my strongest motivations for applying to medical school had been the idea of becoming a member of a highly educated fraternity, a group whose dedication and training put it beyond the trivialities and pettiness of everyday society. Needless to say, I no longer labored under that delusion; it had been riddled early in medical school. Nevertheless, the competition to get in was so keen that if you made it to one of the top few medical schools, it almost invariably meant mat you had really whizzed through college, usually with straight A's. Therefore, the guys who had to settle for their fifth or sixth choice of medical school usually felt like victims of a system in which performance was gauged by the harsh and immutable reality of the transcript. They thought the ivory-tower types looked upon them as second-class citizens. It was all nonsense. Everybody came out on the other side of that huge medical machine looking and thinking exactly the same, and with the same license to practice medicine. In fact, it was the sameness of these men that frightened me, not their differences, which were superficial. I had begun to suspect of late that the machine was producing a lopsided product.
Scrubbing is an invariable, monotonous, ten-minute routine. First under the nails, then a general wash, then the brush. Each surface in turn up to the elbow, then each finger. Start again. Back and forth.
The scrubbing done, I backed through the door, ass first — the perfect symbol of the intern's position — my hands raised in surrender and submission. That’s too theatrical. Actually, I was resigned by now. After all, it had been my own decision to go into medicine; no Romeo had ever panted harder after his Juliet. Too bad she had turned out to be such a bitch. These pseudophilosophic ramblings bore no fruit, changed nothing, but they did help to pass those interminable hours in the OR.
Towel, gown, then gloves, from a rather perfunctory nurse whose eyes I couldn't catch, and the routine was complete. We draped the patient while the surgeon, who was part Hawaiian, and the anesthesiologist, an Oriental, maintained a half-intelligible conversation in pidgin English.
"I go Vegas next week. You want go?" It was the anesthesiologist, looking blankly over the other screen.
"What, you think I that kind gambler?"
"You surgeon, you dat kind gambler." "Fuck you, pake. At least I ain't no fly-by-night gas passer."
"Ha! No gas, no work for you, kanaka."
I was on the right side of the patient, between the surgeon and the anesthesiologist, so that such priceless wisdom and Hawaiian linguistic exotica had to go right by me. The resident stood on the other side, inscrutable.
With everything ready, the surgeon picked up a knife and made the skin incision under the right rib cage. About halfway through the cut, everybody realized that the patient wasn't anesthetized deeply enough. In fact, he was twitching and moving about as if he had a generalized, unbearable itch. The surgeon and the anesthesiologist simultaneously gave nervous little laughs, the surgeon's a bit cynical, because he actually wanted to tell the anesthesiologist he didn't know what the hell he was doing. I don't know why the anesthesiologist laughed, except maybe to fend off the surgeon's broken-record sarcasm. Surgeons are not known for their tact or their love of anesthesiologists.
"Hey, brudda, whatcha madder wich ya? You saving da kind
gas for the next patient? Geevum, man, geevum."
The anesthesiologist didn't say anything, and the surgeon continued, "Looks like we going to do this case with no help from the gas passer."
I was unavoidably a kind of referee in this verbal pugilism, literally squashed against the draped anesthesia screen by the surgeon. Not until they were finally inside the belly was I handed the all-too-familiar handle of a retractor, the intern's joy and raison d'etre. There are thousands of different kinds of retractors, but they all do the same thing: hold back the edges of the wound and the other organs so the surgeon can get at his target.
The surgeon positioned one of the retractors to his liking, motioned for me to take it, and told me to lift up rather than pull back. Well, I'd lift up for about two or three minutes, and then I'd pull back. From where I was standing, my leverage on the retractor handle was negative. Two or three minutes was my limit. "Lift up, goddamnit. Here, let me show you." The surgeon took the retractor out of my hands. "Like this." Amid further comments on my ineptitude, he lifted on the retractor for about two seconds before giving the handle back to me, whereupon I lifted up for two or three minutes and then pulled back. It was unavoidable. Show me the man who can lift up rather than pull back through a five-hour cholecystectomy, and I'll follow him to the ends of the earth.
Cholecystectomy is simply the medical name for the removal of a gall bladder. The gall bladder is tucked far up under the liver, and the intern is needed to pull back the liver and the upper portion of the incision so that the surgeon, with the help of the resident, can take it out. The gall bladder is a pretty unreliable organ, and, therefore, removing it is one of the most frequent surgical procedures. Of all the memory aids I'd learned in medical school, I best remembered the one about the average gall-bladder patient: the four fs—fat, female, forty, and flatulent.
Throughout the operation, my arms were more or less under the surgeon's left arm. He was pivoted away from me, presenting his back, which totally obscured the incision, somewhere over his shoulder. When the anesthesiologist switched on his portable radio and began glancing through a newspaper, and the surgeon began alternately humming and singing, both out of tune, the scene came less and less to resemble the tense silence of medical school — except for those outbursts of displeasure by the surgeon. They were the same.
"Okay, Peters, take a look." I peered over into the incision, a red oozing hole with surgical tapes holding back the abdominal organs. There was the gall bladder, the cystic duct, the common duct, the… "Okay, that's enough. Don't want to spoil you." The surgeon moved back, muscling me out, chuckling with the anesthesiologist. The operating room is a feudal world, with an absolute hierarchy and value system, in which the surgeon is the divine and almighty king, the anesthesiologist his sycophantic prince, and the intern his serf, supposedly grateful for any small scrap of recognition — a look inside or perhaps even the chance to tie a knot or two. That glimpse into the wound had been my reward for being there holding the retractors and watching either the surgeon's back or the hands of the wall clock as they crept slowly around.
The atmosphere was congenial enough, however, until the surgeon asked for the operative cholangio-gram, an X-ray study, to make sure he had the common duct well cleaned of gallbladder stones. This could be determined by injecting an opaque dye into the ducts and then X-raying the area. Any remaining stones would stand out.
When no X-ray technician appeared magically at the snap of his finger — all were busy on other cases — the surgeon cursed and waved his scalpel about, threatening dire reprisals. The nurses were immune to this display, as was the anesthesiologist, whose radio continued to drum out its patter of music and news. This familiar scene was played just about every time the need arose for a mid-operation X ray.
A technician finally came and took the shot, returning in a few minutes with a foggy blur, which the surgeon pronounced the most inept attempt since Roentgen himself. Did he want another taken? No! There is much to learn about the surgeon. I was sure, on reflection, that he wanted that X ray because he had read about it in some journal and thought it would look good on the operative record. The practical effect of the X ray was at best neutral — the way he utilized it, at any rate.
The next day a radiologist would struggle with the X ray, trying to figure out which end should be up and why the hemostat showed in the middle of the ductal system. His report would be sheer guesswork. The unhappy ending of this episode would come later, when the surgeon said something sarcastic to the radiologist, who would smile wryly and reply that if the surgeons could organize themselves a little, radiology might be able to do something. In truth, the surgeons are often at war with everyone— with radiology, pathology, anesthesiology, the operating schedule, residents, nurses, interns — constantly surrounded, they feel, by an ungrateful and inept staff. In a word, many of them are quite paranoid.
Once the retracting had been completed, I prefaced a request to leave with a brief explanation about Mrs. Takura and was excused from the rest of the cholecystectomy. As I stepped out of the operating room into the corridor, the surgeon was still deep in his complaint about X-ray and the anesthesiologist still absorbed in his newspaper.
The work had already started on Mrs. Takura when I began scrubbing the second time. I could see the chief surgical resident and the first-year resident, Carno, busily inserting subcutaneous clamps. Carno and I had come to Hawaii at the same time, for the same reason — to get away from the pressure and have a little fun. In the first few days we had hit it off pretty well, and had even considered getting an apartment together. But now our schedules made it hard to get together.
Friendship among medical people is difficult and elusive, much harder than in college. There is so little time for it. Everyone tends to draw more and more inward, become almost autistic, even when free. In the later years of medical school, the on-call schedules are so different that you can't count on anybody showing up for dinner or a party. Sometimes I couldn't even count on myself. I'd often make plans and then feel too washed out to carry them through.
Also, there was the unavoidable competition. It had settled on us from our very first day, like the spores of a fungus, beginning with the premise that medicine was at its zenith in the research-oriented university center. That was where the "good guys" ended up. To get there, you first had to have a residency at a university center, and for that you needed an internship in one of a handful of princely hospitals. We had been told right off that the top four or five in the class would be asked to stay on as interns, the golden ticket to advance one more giant step. Pressure! There were about 130 of us, all good students in college, and all stumbling around in a haze, sopping up facts as fast as we could and accepting the value system that told us we had to stay on the top. The alternative, too horrible to contemplate, was that we would FAIL and end up in a small-town general practice. That was made to sound bad, really bad, like going from the executive suite to the mail room.
It didn't make any difference if you did well; everyone in the group could do that. After all, we were horses trained to run, and we ran like hell. The real point was to do better than the next guy. That didn't create a congenial environment for friendship, especially when you were short of time, and the time you did have you invariably wanted to spend with a girl.
The system affected that, too, especially during the last couple of years. At first, being a medical student gave you a certain mystique at cocktail parties— everybody thought you were sure to make it into the big money someday. But gradually, since your schedule was so screwed up, you couldn't count on being anywhere at the right time, and you came to be considered a bad risk. All those lovelies from Smith and Wellesley, the ones you were used to, drifted away to more fertile ground. So we had turned to the girls who were there, the ones with the crazy schedules just like ours. And they turned to us. The hospital was full of girls — technicians, instructors, nurses, nursing students — many of them damn nice, and most of them conv
eniently available.
As our training forced us into the mold, we withdrew into ourselves and into the artificial world of the medical school and the hospital. The change was imperceptible, almost unconscious, but steady; once on the escalator leading to the ivory tower, we stayed on it, intellectually. Even though I'd come to Hawaii, I hadn't split totally. Never would. I still had a foot in the door back east; at least, I hoped so. I wasn't a rebel or a revolutionary, just a little worried about where I was going.
Right now I was going into the OR with Mrs. Takura, backing in again with my hands up, ready to be gowned and gloved. They were just getting into the abdomen, and the chief resident motioned me to his left side. After I had squeezed into my position between him and the anesthesia screen, he handed over the legendary retractors and we settled, in, this time for eight hours.
It was hard to recognize nice old Mrs. Takura. Instead of being her usual agreeable and considerate self, she was bleeding all over the place. She had had a cholecystectomy several years back, and it was difficult operating through all the adhesions and fibrous tissue. About two hours into the operation, we took time out to plug a little puncture in the bowel, and then a strong "bleeder" that was squirting on Carno's chest. As her blood pressure sagged, full bottles of blood replaced the empty ones. It was a tough, long procedure, but the chief resident seemed to be doing a good job. Any levity that might have existed earlier disappeared as fatigue crept over us.
Although you would never know it from watching television, humor plays a big part in the operating room. To be sure, it is often grisly, and often at the expense of an unwitting and innocent patient. Most surgeons can regale an operating team for hours with bizarre and off-color tales from the past. With my limited experience, and therefore a limited repertoire, I was mostly silent during these performances, but just before getting serious about Mrs. Takura, when everybody was still feeling good, I ventured a story that was a favorite in my medical school.