by Robin Cook
I was quite concerned about this second knot on the cystic artery. It was the single most important tie of the whole operation. If it fell off some days later, the patient could bleed to death internally. With this in mind, I ran down the first throw and then peered into the hole. It looked okay. Involuntarily, I glanced at Simpson, who didn't complain. So I finished it, and then cut through the artery between the ties, beginning the isolation of the gall bladder.
Next came the cystic duct, through which the bile normally flows. I handled it the same way, tying it with two sutures and then cutting between the knots. Once the gall bladder was isolated, I tensely ran a scalpel lightly around its bed so that just the outside layer of glistening tissues parted. With the scissors, I began to lift the gall bladder away from the liver.
"He's making this look difficult," kidded Simpson.
"If he takes much longer, the thing will develop gangrene." I hardly heard him. The whole operation was only twenty-five minutes old.
With one more gentle cut and a tug, the gall bladder came free. I plopped it in the pan proffered by the nurse. With her other hand she gave me a needle holder with 3–0 chromic suture. Picking up the tissue from the edge of the gall-bladder bed and pulling it over the exposed hepatic duct and right hepatic artery, I took a stitch and tied it down firmly. Too firmly. The suture broke. Another, same place, tied this time with more care, less tension. Then with a running stitch I closed the gall-bladder bed.
After removing the towels used to separate the gall-bladder area from the other internal organs, I began to close. The nurses started their sponge and instrument count to make sure I hadn't left anything behind. All was in order. Carefully I identified all the levels of the abdominal wall, especially the tough fascial layer, which had retracted back out of sight. Stitch after stitch went into the wound, with both the surgeon and the resident helping me tie. I dug the curved needle into the lower side, took it out through the incision, repositioned it with my left hand, then through the upper side. Layer by layer I closed the incision, as if shuffling a deck of cards, watching them snap together and overlap. Finally the skin. When it was over a soaring confidence came over me, like the feeling you get at the end of a good wave when your board breaks out of the white water. As I snapped off my gloves, the resident returned my earlier compliment. The world was mine.
Accompanying the patient down the hall to the recovery room, I was still on a high. Two nurses took charge of the patient while I wrote postoperative orders and dictated the operative note. Then the fatigue came back, hard. I was hungry, too, and I decided to eat, because I hadn't had anything but those two slices of bread since supper the night before, nineteen hours ago; it was 2:00 p.m.
Outside the hospital it was pouring rain; had been all day, I guessed, since water was standing in the low spots. The sky swirled with gray clouds chased in over the island by strong kona winds. It was raining so hard I could barely see the coffee ship a hundred yards away. As I ran the breeze ruffled the puddles of water collected under the overhang. I felt my luck go off a little when I saw Joyce across the room, and, sure enough, she immediately came over to join me. With plenty of other people near us busily talking about the rain, the Hula Bowl, and what not, Joyce said little at first, which suited me. Then, as if by signal, everyone else left and Joyce started in.
"Have you been thinking a lot?" she asked.
"About what?" I was curious.
"You know, about us, like you said you'd do."
"Oh, about us. Yeah, I've been giving it some thought," I said.
"Well, I have, too," she added, sitting up a little. "And I think we should be more open with each other."
"You do, huh?" I was slightly sarcastic, but not enough for her to notice.
"We just haven't been telling each other enough about our feelings and our thoughts," she added.
She was wrong there. She had been telling me too much, especially about how terrible it was sneaking down those back stairs. Uneasily, I realized she was only a step from proposing an instant cure to sneaking around — marriage. She was slightly out of control.
"You had been telling me what was on your mind pretty well," I said. "You never stopped talking about those stairs and how lousy everything was."
"Well, that was getting very uncomfortable," she said righteously.
"Uncomfortable. Well, that’s true. Why don't you do something about your Miss-Apples-and-TV so we can go to your apartment like normal people?"
"My roommate has nothing to do with it."
"Your roommate has a lot to do with it. If it weren't for your roommate, we could stay over there at your apartment, and you wouldn't have to sneak down the stairs."
"You don't care about me at all," she said petulantly.
"Of course I do, but that’s not the point. If you—"
"It is the point," she interrupted.
"You're changing the subject," I protested.
"Well, it's the only subject I'm interested in," she said staidly, standing up and scraping back her chair. "Anyway, I've decided you can stop thinking about us, and drop dead." She strode out indignantly.
Drop dead. A great suggestion. Actually, the idea held a kind of morbid appeal. I was that tired. With Joyce gone, the room moved away from me suddenly. A lot of people were still sitting around other tables, but not a soul was there with me. The sounds of a hundred voices mingled, all distant and incomprehensible. Staring through the window at the rain and the gray scudding clouds, I chewed absent-mindedly, overcome by loneliness. Nothing remained of that good feeling after the gall bladder; in its wake, I was simply drained of all emotion. Looking at the clock, I realized I had been going full steam for thirty hours. I thought about the clinic, and that I should go over there. Interns are supposed to help with outpatients in their "free time." But in my state I wouldn't be of any use. To hell with the clinic.
Raindrops danced around the overhang as the wind whipped them into sheltered areas. It was surprisingly cold. When tired, the body cannot tolerate much in the way of temperature variation. So the chills I felt coursing through me were probably more a product of my physical condition than of the weather. I hurried along, concentrating totally on my bed, anticipating the pleasure. All interns develop an extraordinary appreciation for simple things others take for granted — free muscular movement; the right to relieve an itch, void one's bladder, or empty one's bowels; more or less regular meals; a decent amount of sleep. In bed, I felt my body sinking, growing tremendous and filling the room, until my huge body and the room gradually merged, became one, and I slept.
The abscess was small when I began, no more than a pimple. Now it was enormous, covering most of the left arm and growing. No matter how much I cut, more appeared; now it crept toward the shoulder. Behind me, Hercules was whispering to the Supercharger, "He'll never make it. Neither will the patient." For encouragement, I looked toward Simpson, who said, "Get it right the first time, Peters, or it's Hicksville for you." In one final, desperate effort, I slashed to the bone through tissue, and to my horror I severed the ulnar nerve, immobilizing the hand forever. Time's up, I thought, as the bell rang; failure! It was, of course, the telephone. I leaped to answer it, still half in the dream and confused by the light. Had I missed rounds? No, they weren't until five o'clock, and my watch indicated three. It was surgery. I had been put on a case scheduled to start in fifteen minutes.
Hanging up, I slowly regained orientation. Why should I have waked up in such a state of terror? Then I connected the dream with the incision and drainage I had done yesterday on a huge elbow abscess. After opening the abscess with a sharp blade, causing a spontaneous flow of pus, I had pushed in the tip of a hemostat clamp to insure good drainage. But the abscess was much deeper than I had expected; it seemed to extend to the area of the ulnar nerve. So I had cut down and down, never truly getting to the bottom of the abscess and finally quitting for fear I would cut the ulnar nerve, if I hadn't already. Anyway, I decided to stop by now and check th
e case on the way to surgery.
The fright reflex had gotten me out of bed, but then my state of physical disintegration began to finger its way back. After having been up for so long, sleeping less than an hour just made everything worse. Nothing about me seemed to work right; I felt dizzy and slightly nauseous when I stood up after putting on my shoes. Unfortunately, I looked into the mirror — a serious mistake, because I realized I would have to shave to join the living. My hand was shaky, and, as usual, I cut myself a couple of times, not badly, but enough so that the blood kept running despite tissue, cold water, and a heavy, stinging application of styptic pencil.
I hurried over to the ward. It had stopped raining, although clouds still hung thick and heavy over the hills. My abscess patient was probably a bit startled when I ran into the room and asked him to hold up his hands and spread his fingers. As he did so, I tried to compress all the fingers together and got good resistance; that indicated his ulnar nerve was all right. I didn't have time to see anybody else except my waterlogged edema patient, whose bed was right next to that of the abscess. He had a question about his diuretic pills that I couldn't ignore.
I had developed a great respect for serious edema cases of the sort that requires a lessening of body fluids by one kind of diuretic or another. My awakening had been sudden and brutal — a carcinoma patient, transferred from a medical ward, who had swelled up through total body edema, a condition called anasarca. I decided that she was in that state because the medical department had missed the boat; there was always a little friction between those who cut — the surgeons — and those who treated with drugs — the medicine guys. This patient had cancer, diagnosed from a lymph-node biopsy. Although the primary site had never been found or the exact type of cancer determined, somebody decided to zap her with radiotherapy, which did nothing to the cancer, and then with chemotherapy, which was equally useless. Meanwhile, the patient was on IV's, and the medical boys allowed her to gather so much water that her sodium and chloride levels dropped to the point where she was practically delirious. And they ignored her plasma proteins, which dropped as well. When I got the patient, I was determined to get rid of all that water. By giving her some albumin and a diuretic, I achieved some diuresis, and hence a slight improvement in the edema. But I wanted more. When I tried to get some advice, nobody was much interested, including the attending. Since her urine was alkaline, I decided to give her a good dose of ammonium chloride with the diuretic, and this time the results were spectacular. What a diuresis! Water. poured out of her as her urinary output soared. It was terrific, amazing — except that it would not stop, and overnight she dried up like a prune. Bronchopneumonia set in immediately, and she was dead in a day and a half. I had never said anything more to the medical guys about the case, but I was wary now of those diuretic agents. I was being very careful with this man next to the abscess. He was taking only pills.
Actually, I had learned to respect abscesses as well. There had been one patient — not mine, although I had seen him on rounds every day — who was admitted because of spreading cellulitis in his right leg from an abscessed area. When he came to us, most of his calf muscles had already liquefied. We cultured a number of different organisms out of that abscess; they all seemed to be working together against the patient. One day, when the intern handling the case was sick, I had to drain it. The smell was indescribable; once again I resorted to my three-mask ploy to keep from retching. As I attempted to open the abscess cavity, I realized that it went in every direction, as far as the hemostat would reach. An argument had raged off and on during rounds about whether his leg should come off, but advocates of a new method of continuous antibiotic perfusion won out — at least, they won the argument — and dripped gallons of antibiotic into his leg, seeming to stabilize him for a few days. But suddenly, one day while we were looking at him on morning rounds, the man died. We had just walked up to the bed, and another intern had started to say that the patient was "essentially unchanged." Odd, how often that word "essentially" was used on rounds. This man had been in liver failure, heart failure, kidney failure — in fact, total body failure. But just as the intern was mouthing his neutral status report the patient gasped, and it was over. It seemed an act of enormous bad taste. We stood there dumbfounded. No one tried to resuscitate him, because all of us had become used to the hopelessness of his condition. Our insignificant drugs had only supported him precariously for a while, until the bottom fell out, as it had with those Gram-negative sepsis cases in medical school. It was as if he had absolutely no defense against the infection. Thus I came to respect abscesses. In fact, as time went on, I was learning to respect every illness, no matter how innocuous it appeared to be.
Now I was hurrying on to surgery, already late. There was a lot of activity on the medical floor. I passed interns, residents, and doctors standing around beds talking, as they always were — unless they were sitting around talking in the lounge. Most discussions centered on treatment, on which drugs to use. As a point of agreement would near on some medication, one of the participants would bring up a side effect, whereupon a drug would be suggested to counter the side effect, which drug could, in turn, have its own side effect. Which was worse, the question now became, the second side effect or the original condition? Would the second drug make the original symptoms worse than they were before the first drug made them better? On and on it went, around and around, until usually the discussion got so complicated it seemed best to start again, on the next patient. Or that's what the medical wards looked like to me. Talk, talk, talk. At least, in surgery we did something. But the medical guys pointed out, with some truth, that we just cut it out when we couldn't cure it. We countered that cutting it out did, in fact, often cure it. The argument went inconclusively back and forth, always conducted in an entirely friendly, even jovial, style, but its roots sank deep.
Climbing into another clean scrub suit was a compounded deja vu. I was beginning to live in those things. Since no medium sizes were left, I had to wear a large, and the strings of the pants went around me twice. Through the swinging doors into the OR area. While I was putting on my canvas shoes, I glanced at the board to see who was doing the operation. Zap! It was none other than El Almighty Cardiac Surgeon. But what was he doing here? The procedure was listed as "Abdominal abscess, dirty," and obviously El Almighty usually worked in the chest. Strange things had ceased to surprise me, however. As I looked up, he saw me and greeted me by name, being very friendly, but I knew better than to lower my guard. It was just the first move, a condescending act early in the show— especially since he had to shout the greeting from halfway down the corridor to make sure everyone noted his good cheer and camaraderie.
I remembered wryly one time when a resident and I were assigned to a cardiac case with not one, but two such surgeons. These men, completely alike in manner and hidden behind masks, could be distinguished only by their girth, one being much fatter than the other. That case had begun smoothly enough, with affability and backslapping all around. Suddenly, with no warning whatever, one of the surgeons began to harangue the resident for giving blood to a patient dying of lung cancer. True, the decision was debatable, but not serious enough to warrant such a tirade in front of all assembled. He was just puffing himself up, improving his self-image. So it went throughout the operation, praise and then blame, each overdone, until we reached a kind of frantic crescendo of invective that gradually ebbed away, back into good humor. It had been like a madhouse.
There is something of this in many surgeons — a kind of unpredictable passive-aggressive approach to life. One minute you are a close and valued friend; the next, who knows? It was almost as if they lay waiting in ambush for you to cross some invisible line, and when you did—wham! — you got a fireworks of verbal abuse.
Perhaps this is a natural effect of the system, the final result of too much intensity and repression through too many years of training. I had begun to feel it in myself. If he wants to get ahead, an intern learns to ke
ep his mouth shut. Later, as a resident, he learns the lesson so well that it becomes internalized. Underneath, however, he is angry much of the time. No matter how cleansing it might have been to tell some guy to stuff it, I never did, and neither did anybody else. Being at the bottom of the totem pole, we naturally aspired to rise higher, and that meant playing the game.
In this game, fear was symbiotic with anger. If anything, the fear portion of it was more complicated. As an intern, you were scared most of the time; at least, I was. At first, like any good little humanist, you were afraid to make a mistake, because it might harm a patient, even take his life. About six months along, however, the patient began to recede, becoming less important as your career went forward. You had by then come to believe that no intern was likely to suffer a setback because of official disapproval of his practice of medicine, however sloppy or incompetent. What would not be tolerated was criticism of the system. No matter that you were exhausted, or were learning at a snail's pace, if at all, and being exploited in the meantime. If you wanted a good residency — and I wanted one desperately — you just took it without a murmur. Plenty of hopefuls were lined up to take your place back there in the big leagues. So I held feet and retractors, and took the other shit. And all the time the anger ate at me.