by Robin Cook
It seems that an enormously obese lady had once appeared at the hospital during a time when the OR was covered only by two interns and a resident. She complained of an agonizing abdominal pain. Elbow deep in fatty tissue, the three examined her, conferred, re-examined, and conferred again, unable to agree on a diagnosis. Finally those who thought she had a hot appendix won out, and up the lady went to the OR, where she was literally draped all over the table. Hearing of the action, a small band of six or seven others had gathered by the time the resident began cutting down through the layers of fat toward the peritoneal cavity. After repositioning the retractors several times, as he moved in deeper and deeper, he suddenly stopped and had the overhead light readjusted. Then he asked for a pair of tongs, and while everyone watched in anticipation, he brought up through the lady a piece of white cloth. A stunned silence fell over the assemblage until, simultaneously, everyone realized that the resident had cut all the way through to the operating table. The patient's abdomen, being so large, had skewed off to the left, causing the resident to miss the abdominal cavity entirely.
But the laughter from that story had long since drifted away. We labored now inside Mrs. Takura, and the muscles in my hands and arms were numb from maintaining tension on the retractors in that awkward position hour after hour. As lunch-rime approached and receded, my stomach growled in protest, a counterpoint to the itch on my nose. My bladder was so full I didn't dare lean against the operating table. Time crept on. I seldom saw into the wound, although I could tell what was happening from the surgeon's comments. Fastidiously the vessels were sewn together — a side-to-side anastomosis — and the final suture was placed and run down with tired fingers. When I was at last relieved of the retractors, I couldn't even open my fists; they stayed clenched until I bent the fingers back one by one and soaked them in warm water.
Although it was almost four o'clock, we were not through. We still had to close. Like all the others, I was tired, hungry, and uncomfortable in every way. Suture after suture, wire, silk, wire, slowly working up the long incision, starting from the bottom and working with rapid ties, the gaping portion very slowly but progressively drawing closed until the last fascial suture. Placed. Then the skin. By the time we snapped off our gloves at the finish it was past five — the beginning of my glorious night off.
I urinated, wrote all the postoperative orders, changed my clothes, and had some dinner, in that order. As I walked across to the dining room, I felt as if I'd been run over by a herd of wild elephants in heat. I was exhausted and, much worse, deeply frustrated. I had been assisting in surgery for nine straight hours. Eight of them had been the most important hours of Mrs. Takura's life; yet I felt no sense of accomplishment. I had simply endured, and I was probably the one person they could have done without. Sure, they needed the retraction, but a catatonic schizophrenic would have sufficed. Interns are eager to work hard, even to sacrifice — above all, to be useful and to display their special talents — in order to learn. I felt none of these satisfactions, only an empty bitterness and exhaustion.
After supper, even though I was not on call, the usual ward work was still to be done, and I moved perfunctorily through a series of dressings, drains, and sutures. I rewrote IV orders, looked over laboratory reports, and did a history, physical, and preoperative preparation on one new patient, a hernia. Roso's hiccups had started again as he came out of his hibernation with the Sparine. Anything I wanted to ignore I did so by leaning on my tiredness, rationalizing. I avoided even looking into Marsha Potts's room.
Sleep was impossible, though I had been without it for most of twenty-four hours. Besides, I wanted to go somewhere away from the hospital, to talk with somebody. My confused and angry thoughts were rocketing around in my head too much for me to deal with alone. Carno couldn't be located anyplace; probably he was with his Japanese girl friend. But Jan, thank God, was there and available. She wanted to go for a drive, perhaps a swim. She wanted to do anything I wanted to do.
We drove eastward, moving toward the silvery violet of the evening. The road took us up over the Pali to the windward side of the island, gradually climbing and opening out the view of the colors from the setting sun on the expanding panorama of ocean behind us. The scene had a poetry that kept us silent until we were through the tunnel and out in the shadow again, in Kailua. There we found a beach where we were alone. My head gradually cleared of hostile thoughts, and the prison of the day, with its creeping clock and stiff fingers, seemed far away as I floated in the shallow water, letting the small exhausted waves rock me with their surge. Later we lay on a blanket and watched the stars come out.
Wanting to hear Jan talk, I asked her questions about herself, her family, her likes and dislikes, her favorite books. All at once I wanted to know all about her, and to hear her tell it in her small, soft voice. She grew weary of this after a time and asked me about my day.
"I spent all day in surgery."
"You did?"
"Nine hours."
"Wow, that’s wonderful! What did you do?"
"Nothing."
"Nothing?"
"Well, practically nothing. I mean I was the retractor, holding back the wound edge and the liver so that the real doctors could operate."
"You're silly," she said. "That was important and you know it."
"Yes, it was important. But the problem is that anybody could have done it, anybody at all."
"I don't believe it."
"Yeah, I know you don't believe it. Neither does anybody else. No one thinks that anybody but an intern can take an intern's place. But let me tell you, in that operating room, no one could have done the nurse's job except another nurse, ditto the anesthesiologist and the surgeon. But me? Anybody! The guy off the street. Anybody at all."
"But you have to learn."
"You hit the problem on the head. The intern is frozen in one spot, eternally retracting. They call it learning — that's the rationalization — but if s a hoax. You learn enough about retracting after one day. You don't need a year. There's so much to learn, but why at this snail's pace? You feel so damn exploited! They ought to hire people to retract, and put the intern over there tying knots and watching the surgeon work."
"Can you tie good knots already?" she asked.
That stopped me. I could remember telling her that I wasn't very good with knots, but still, her comment seemed discouragingly off the mark. It indicated that I wasn't getting through to her and it was useless to try. Even so, I felt better, almost as if my own thoughts had focused. I told her no, I couldn't tie very good knots, but I'd probably learn if they gave me the job.
She was getting to me again, turning me on. We ended up running through the shallow water. She was so beautiful, so full of life, I wanted to yell with joy. We kissed and held each other close, rolled up in the blanket. I was wild for her, and knew that we were going to make love, and that she wanted to as much as I did. But she felt obliged to talk some more first, and tell me some personal things about herself. For instance, that she had made love to only one other boy, but that he had tricked her because it turned out that he hadn't really loved her. This went on for five minutes or so, slowly turning me off again, and I decided that making love was probably a bad idea, after all. She couldn't believe this, and wanted to know why. The real reason, my inner frustration, would not have satisfied her. Instead, I told her that I loved the sheen in her hair and her sense of life but I didn't know if I loved her yet. That pleased her so much she almost made me change my mind again. Driving back to the hospital, I got her to sing "Where Have All the Flowers Gone?" over and over again, and I felt at peace.
"You think you didn't do anything today, but you did," she said, suddenly turning toward me.
"What was that?" I asked.
"Well, you saved Mrs. Takura's life. I mean, you helped, even if you thought that you should have been doing something else."
I had to admit her point, a very nice point, which I had almost forgotten. For Mrs. Takura I wou
ld stand holding a retractor for weeks.
Back at the hospital I jumped into my whites and dashed over to the ICU to see how she was doing. Her bed was empty. I looked at the nurse, questioning, holding back the thought.
"She's dead. She died about an hour ago."
"She's what? Mrs. Takura?"
"She's dead. She died about an hour ago."
As I stumbled back to my room, my thoughts piled up, tumbling over into tears, draining me of every thought except that the day had been a horrid abortion, unredeemed even by the act of love. In bed, I fell into a troubled sleep.
Day 172
Emergency Room
My ears were trained to separate its sound. Somewhere off in the distance I could hear the unmistakable high-pitched undulations building and cycling, growing progressively louder as it drew near. The clock said 9:15—a.m. I was seated behind the counter of the emergency room — waiting.
For some people, even those closer to the ambulance than I, the siren would be inaudible, mixed with the general background noise. Others, aware of their good health, or unaware of their bad, would be content to let the siren diminish, melting away into the subconscious, intermingling with the noise of cars, radios, voices. For them it was a distant thing. It belonged to someone else.
For me it invariably got louder and louder, because I was the intern assigned to the emergency room— the ER to those who knew and loved it. My duties in the ER could be subsumed under the title of official hospital welcomer to all who came. And come they did — the young and the old, the sleepless, the depressed, the nervous, occasionally even the injured and the sick. There I worked, often feverishly; I frequently ate; I occasionally sat. But, always waiting for the dreaded ambulance, I almost never slept.
Its sound meant trouble, and I was not ready for trouble, nor did I believe I ever would be. Although I had been assigned to the ER for more than a month, and had been an intern for almost half a year now, my most prevalent emotional state was still one of fear. Fear that I would be presented with a problem I couldn't handle and would screw it up. Ironically, I had been plunged into this new environment, one that demanded radically different medical choices, just when I was beginning to develop a certain degree of confidence on the wards and in the OR. Except for a group of highly capable nurses, I was on my own in the ER, solely responsible for what happened. It was not so bad during the day, when other doctors were around — the house staff was only a few seconds away — but at night five minutes, maybe even ten, might pass before anyone else from the house staff arrived. So things could be crucial. Sometimes my hand was forced.
Even the schedule in the ER was different. On duty twenty-four hours, off twenty-four. That doesn't sound so bad until you do it for a solid week. If your work week starts at eight on Sunday morning, by eight Wednesday morning you have already worked forty-eight hours, with another forty-eight to go. The result is that after two weeks your system is in total rebellion: you have headaches, loose bowels, and a slight tremor. The human body is geared to work only so long and then sleep, not go for twenty-four hours straight. Most organs of the body, particularly the glands, must rest; their function actually changes in a time-honored way over a twenty-four-hour period, whether the whole body sleeps or not. So after sixteen hours on duty your glands have more or less gone to sleep, but the same decisions are there to be made, with the same consequences. Life is no sturdier at 4:00 a.m. than it is at 12:00 noon. In fact, some studies suggest that it is frailer. Your patience hardly exists, everything is a struggle, the slightest hindrance becomes a major irritation….
The siren approached, very near now. I listened hopefully for the end of the build-up and the receding Doppler effect that we occasionally got as an ambulance sped off to one of the smaller hospitals nearby. Not this time. I couldn't see it, but I could tell from the way the siren suddenly trailed off that it had entered the hospital grounds. Within seconds it was backing up toward the landing, and I was there to greet it.
Through the small rear windows I could make out the chaotic resuscitation efforts of the ambulance crew. One of the attendants was giving closed-chest cardiac massage by compressing the patient's breastbone; another was trying vainly to keep an oxygen mask on the face. As the ambulance stopped I reached out and twisted open the door. A few passers-by paused and looked over their shoulders. To them the event was closed. The ambulance had arrived, the doctor was waiting with an assortment of strange and miraculous instruments at hand, all was saved. For me it was just the beginning. I was glad that no one could see into my mind as I tried to prepare for what was to come.
"Bring him inside to Room A," I yelled to the crew as they slowed their resuscitative efforts. I helped lift the stretcher out and roll it fast through the short hallway, asking how long it had been since the patient had made any respiratory attempts, any sign of movement or life.
"He hasn't, and we got to him about ten minutes ago."
He was a bearded man of about fifty, and so large it took all of us to lift him onto the examining table. Seconds stretched into what felt like hours as the necessity for making a decision drilled into me — the kind of decision that isn't much discussed outside hospitals. I must either call a cardiac arrest or declare this simply a case of DOA — dead on arrival. Surely it was unfair to demand such a decision based on what I could remember from a textbook! Still, it had to be made, and made fast.
What would happen if I called a cardiac arrest? Six weeks earlier, we had restored a man to life after only eight minutes of clinical death. He lay now in the ICU, a vegetable, alive in a legal sense but dead in every other way. Seeing that man day after day, I had come to feel that in giving him the half life technology made possible we had somehow deprived him of dignity. For six weeks the body had functioned — the heart beating, the lung mechanically pumping, the eyes dilated and empty; and his relatives were being drawn out to the limit of their emotional and financial reserves. Whose hand will dare to pull the plug on the machine that breathes, whose will cut off the IV, whose mind relax the attention necessary to maintain a proper ionic concentration in the blood stream so that the heart can beat on forever without the brain? No one wants to kill the grain of hope that lingers in even the most objective mind.
But there is the problem of the bed. It is needed for others — people who perhaps are more alive, and yet will be just as dead if deprived of the resources of the ICU. It comes down to a decision based on subtle, undefined gradations of life versus death. It isn't a matter of black or white, but of varying shades of gray. What does it really mean to be alive? A perplexing question, the answer to which evades a mind numbed with fatigue.
Where does the exhausted intern look for guidance in these moments? To college, where sterile concepts of truth, religion, and philosophy invariably lead to an automatic acceptance of life as the opposite of death? No help there. To medical school? Perhaps, but in the ivory tower the complexities of the Schwartzman reaction and the sequence of amino-acid cycles have pushed aside the fundamental questions. Nor will there be any help from an attending physician. He always remains silent, perhaps perplexed, but hardened by repetition. And the relative or friend standing by? What would he say if you meekly put forward the proposition that there may be halfway points between life and death? Alas, he cannot think beyond the poor soul that is, or was Uncle Charlie. Unassisted, then, the intern gropes in side himself and makes arbitrary decisions, depending on how tired he is, whether if s morning or night, whether he is in love or lonely. And then he tries to forget them, which is easy if he is tired; and, because he's always tired, he always forgets — except that later the memory may surface from his unconscious. Angry and uncertain, he has once more been tested and found unprepared…
Paradoxically, even with six people around me I was alone, standing there next to the nonbreathing hulk of the bearded man. His extremities were cold, but his chest was quite warm; he had no pulse, no respiration, dilated fixed pupils. One of the ambulance attendants kept ta
lking, telling me what he had heard from the neighbor who had been with the man. The man had called his doctor after an asthma attack that morning, but it had gotten worse — so bad, in fact, that he started toward the ER, driving with a neighbor. In mid trip he had experienced an attack of acute dyspnea, an inability to breathe. He had stopped the car, jumped out, staggered a few steps, and collapsed. The neighbor had run for help and the ambulance was called.
"DOA," I said firmly trying not to show doubt. In fact, my mind was a jumble of loosely connected thoughts racing around in search of a pattern. Strangely, in the ER mornings are an intern's most vulnerable time. Despite the surface refreshment of a night's sleep, his decision-making abilities are undercut by the deep exhaustion of the twenty-four-hour cycle. His experience is insufficient for him to make critical decisions with the certainty not of rational thought, but of pure reflex. One takes for granted the old aphorism that familiarity breeds blind acceptance. And so it is. Very often, in the beginning of his career, the intern is faced with a situation in which his mind is clear enough to think, yet he can find no answers. As with the schizophrenic who cannot handle an overabundance of sensory input, information remains unassociated in his mind. So the intern absorbs these experiences that rush in upon him; they hang around his mind in a loose conglomerate until he is tired enough to relegate them to his unconscious, and eventually he does reach a point at which experience brings familiarity, and familiarity brings acceptance without thought. By then a large part of his humanity has dropped away….
All this mental activity happened in milliseconds. I didn't stand pondering and uncertain while the bearded man lay there. From the time I opened the back of the ambulance to the time he was pronounced DOA, less than thirty seconds elapsed. But it seemed much longer, and it affected me for hours. I did have one thing to be thankful about. My training had advanced far enough so that I would not be popping back in to feel for a pulse.