“Five,” said the technician, speaking over the amplified whoop-whoop heart sounds reminiscent of a Chinook helicopter banking over Saigon. “He’s a sneaky little bugger. Sucks you in, all cute and twitchy and before you know it, bang, he’s feasting on your fingertip.”
I was only half listening now, concentrating on my bit of microsurgery. Unbeknownst to his owner, Pikachu had broken both bones in his shin, severing the delicate blood supply to his foot. All the tissue below the break was dead, black, and shrunken. My mission was to remove the dead tissue, clean up the wound, and get out as fast as possible.
As I was placing the last of my impossibly fine stitches, I said, “What’s this I hear about a paralyzed tree frog?”
I glanced up at the technician, caught her smile, and went straight back to my needle. I was referring to a bizarre rumor swirling around the hospital, a rumor I had caught in snippets and one that deserved my attention.
“What have you heard?” she said, and I didn’t need to look up to know she was enjoying her advantage.
“Can I have some skin glue, please?”
Dr. Hurley disappeared in search of sterile glue. Leaving stitches in the skin of rodents is asking for trouble. Talented incisors will have them out and your work ruined as soon as they wake up.
“Someone told me one of your clients wears a tree frog in her cleavage?”
“It’s true,” she said. “Right here.” She slapped a palm against the V of her scrub top. “A young girl, acts like and dresses like Paris Hilton, but instead of a Chihuahua or a Yorkshire terrier she prefers to accessorize with an aqua-blue tree frog.”
I dug deep for a look that said, “Doesn’t everybody!”
“The poor thing was acting all floppy on its back legs. She wanted to know if it had been poisoned.”
I know nothing about pet frogs but I was curious why the owner would leap to this conclusion.
“Amphibians easily absorb chemicals through their skin,” said the tech, “and when we found out how she likes to show him off in public, poisoning seemed like the most likely cause.”
“Poisoning,” I said. “From what?”
The technician nodded, fighting to keep a straight face.
“Victoria’s Secret Breast Firming Cream.”
Her delivery was perfect, her pause just long enough for me to see the connection.
Dr. Hurley reappeared with my bottle of skin glue.
“The owner confessed to recently using this particular product in an attempt to enhance the contours of her cleavage. Naturally we wanted to find out exactly what chemicals give this magical cream its firming powers and that’s when we hit a wall, the hospital’s Internet firewall. For some reason the IT department didn’t believe us when we told them we needed to surf the Web pages of a popular lingerie company in search of potential toxins.”
I placed a few blue drops on the skin edges and pinched them together, extricating myself from Pikachu and this medical-grade Super Glue before I became his first postoperative snack.
I was about to selflessly volunteer my services for the greater good of cleavage-riding tree frogs everywhere by thoroughly researching the hazardous Victoria’s Secret Web site, when Dr. Able appeared at my side.
“Have a chance to look at your schedule?” he asked. “Squeeze in my spaniel with the lung mass?”
I tried to remember what was lined up over the next few days but now that I had made up my mind it no longer seemed to matter. Any inconvenience would be mine because I needed to make this happen.
“Were you planning a CAT scan first?”
“I wish,” he said, “but the owner just wants us to go get it if we can.”
I paused, wondering if this would come back to bite me on the bottom, and said, “Tell Helen’s owner I’ll do the surgery.”
“Great. But when?”
“Tomorrow,” I said. “Let’s do this first thing tomorrow morning.”
MY meeting with Helen the following morning only affirmed my decision to expose her to Cleo’s magic. She was in a holding cage outside the anesthetic induction area and after checking the labeled band around her neck to confirm her identity, I made my introduction. The first thing that struck me was her independent spirit. Sure, I got a friendly little tail wag but there was no submissive roll over and pee. She was clearly not the kind of dog willing to flirt indiscriminately. In fact she seemed distracted, like someone you meet at a party who abruptly ends a conversation as soon as someone more important comes along. I imagined that someone more important was the person who dropped her off—Eileen.
Though it may seem like a strange confession, I was also pleased by her physical imperfections. Like a cheeky street urchin, she had something of the Artful Dodger about her—the literal “warts and all” texture to her skin, the chartreuse barnacles of dental plaque, the heady bouquet of old sneakers wafting from her ears—which only served to enhance her appeal, her vital authenticity. It further fueled my affection for Helen’s owner, making me respect her motivation even more. This had to be true love.
But as I listened to her heart and lungs with my stethoscope, I began to imagine what some people might think about my mission. Not surprisingly, there will be those who claim I was simply air-brushing my guilt for what had happened to Cleo, that I was finding a solution in order to realize a conviction. And maybe they were right. We all want to feel better about our mistakes. However, now that I was about to take Helen into the bright, sterile world of surgery, it wasn’t my commitment or determination that gave me pause, it was the spiritual basis of the promise that made me uneasy. I mean, aren’t miraculous clinical outcomes the kind of phenomena usually unmasked in retrospect, with hindsight and a vivid imagination, by joining dots, seeing patterns, and discovering a bigger picture? I didn’t want this endeavor to feel too forced, too contrived. I hardly knew Cleo. It wasn’t as though I had much to draw upon. Could I involve Cleo in a prayer I might chant over Helen’s sleeping body? Would that do the trick?
Part of me wished I had something belonging to Cleo with me, like a collar or even a rabies tag, something I could leave in the breast pocket of my scrubs while I performed Helen’s surgery. Years ago a client called Mr. Hartman gave me a cheap religious figurine, supposedly a replica of St. Sergius, the Russian patron saint of animals. I was supposed to take it with me into surgery as a good-luck charm while I worked on his sick dog, a remarkable German shepherd named Sage. Against the odds, Sage pulled through, and though I can’t be sure how much was due to the preternatural powers of a plastic statue (to this day I remain convinced that it was actually a miniature statue of St. Francis of Assisi), St. Sergius has been my secret copilot on several tricky missions. Although his pointy plastic right hind is sharp and uncomfortable, poking my skin when I am mummified inside my sterile surgical gown, at least I am aware of his physical presence with me in surgery. If Cleo was to be my talisman for Helen’s surgery, how would I know she was there?
ALONE at the scrub sink, working the antiseptic froth, I decided to think about the Cleo I had met and the Cleo I went on to hear about from Sandi. I tried to imagine the dog in her stories, the one who comforted a sick child at an airport, the one who befriended a frightened sheltie at a doggy day care. It didn’t feel like much of anything, hardly enough to get a sense of her let alone to summon her spirit, but it was all I had and, best of all, this retrospective didn’t leave me feeling like a fraud.
As soon as I stepped away from the laser beam, the hollow patter of water on stainless-steel sinks came to an end, the silence ushering in a new phase in the proceedings. By the time I walked through the swinging doors into the OR, dripping hands and arms held out and up in front of me like I was about to show off my robot dance moves, I was all the way back with Helen. I was thinking positive thoughts—“surgical resection questionable” turning out to be “surgical resection easier than anticipated.” Like most surgeons, I don’t get a pep talk from a fired-up coach, so I usually rely on optimism. If I d
idn’t think there was every chance I could get this tumor out, believe me, I wouldn’t even have tried.
From here on out, if my memories of Cleo and all she embodied chose to follow me, they would have to do so without help from me. I had a commitment to a spaniel in surgical suite seven, the one lying with her right side down on the table, the entire left side of her rib cage shaved, iodine brown, bracing for the opening slice of my scalpel.
THORACIC surgery necessitates a major violation of basic physiology. Break the airtight seal of the chest and the lungs fail to expand, meaning you breathe for your patient or your patient doesn’t breathe. Like the rhythmic background noise in a Jacques Cousteau underwater documentary, the audible hiss and sigh of a ventilator had to accompany me throughout the nitty-gritty of Helen’s difficult procedure.
First, I counted her ribs. Unlike humans, who have twelve, dogs possess thirteen ribs, and knowing which is which is critical. Based on a correct identification, the surgeon will commit to opening a specific window into the chest. Pick the right window and you get the prize—great view, easy access, simple surgery. Pick the wrong window and you pay the price—restricted view, limited access, difficult surgery. It’s the difference between a free ticket for a private balcony or a seat in the nosebleed section.
Here Helen proved to be less than helpful. Her baby backs were a little too fatty for my liking. My gloved fingers had hoped to find the discrete bony bars of her ribcage, not a series of questionable undulations. My latex fingers puppet walked forward from number thirteen, walked backward from number one. I did it once more to be sure. I pressed scalpel to skin between ribs five and six.
“Cutting,” I said, informing the anesthesia technician that the show was about to begin, forging a six-inch rent down and into the chest cavity. Looking like a medieval torture device, a stainless-steel rib retractor was squeezed into the fissure I had created, its metallic dazzle dancing in my eyes.
The leading edge of an adjacent lung lobe licked the opening like a salacious, foamy pink tongue before slithering out of sight, and for a second I wondered if I had selected the wrong window. Then I got a glimpse of what lay beneath, an apple-sized mass bobbing in a purple bruise of deflated lung. Despite my optimal location I instantly recognized my dilemma. The treasure was big, cumbersome, and buried deep. Its rhythm was all wrong, ignoring the easy to and fro of the mechanical ventilator, preferring to dance to the faster beat of the heart and great vessels.
If ever there was a time for Cleo to have crossed my mind, this was it, as my fingers probed the very essence of this animal—her heart. My professionalism required complete mental focus on the task at hand, but I have no doubt that my subconscious was pursuing its own agenda, detouring through a maze of conversations and promises and images that conspired to buoy me through the difficult task ahead. While there was no conscious act, there was an awareness, something vague and unfocused, lost in the details of more pressing matters, and this was fine by me. If something remarkable was going to happen, it would never be conceived in premeditated thought. Like I said, we can’t make the dots appear, we can only choose to connect them with hindsight. Fate is a retrospective gift.
Most likely my thoughts were overshadowed by a hankering for a smaller hand size or a larger breed of patient. This was going to be tight—one-handed bomb disposal down a rabbit hole. This close to a beating heart, cutting the wrong connection or failing to cut it clean could be fatal.
“I’ll take a TA stapler with two V3 cartridges, if you please.”
If my request for a stapler made you think about your office Swingline then you’re not far off the mark. TA stands for “thoracoabdominal,” and in a manner similar to punching a metal clip through two sheets of paper, this particular stapling device fires three rows of staggered sterile titanium clips across the base of living tissue. With a single and enormously satisfying squeeze of a trigger, its tiny staples compress and seal arteries, veins, and small airways, demarcating a border between what can be safely left behind and what needs to be cut out. However, all my attempts to position the device exposed my single biggest fear—the tumor extended from the very origin of the lung, the root of the large cartilaginous airways and the even larger blood vessels. If this wasn’t inoperable, it was pretty damn close.
Cancer surgery is more than all or nothing. Taking the tumor alone is not enough. The surgeon demands a margin of normal healthy tissue beyond the visible limits of the tumor, just in case the sneaky little bastard decides to extend its microscopic reach. For Helen, here was my biggest problem. Sneaking just one extra centimeter of margin would have compromised the major vessels carrying blood back to the heart. It wasn’t a viable option.
Minutes of surgical indecision passed as I tried to make the call. Perhaps the best way I can describe what I was feeling is to think of the surgeon as a mountaineer, caught in bad weather on the way to the summit. I may have come a long way but up to this point I really haven’t achieved anything. I might be fine, but by pressing forward I am putting the only other member of my team at serious risk. Turn back or keep going. Succumb to resignation and failure or embrace the one certainty that brought us to this point—the need for success. As I wavered over Helen’s beating heart I believe I made the right decision, in other words, one that I could live with.
“I’ll take some suture material, please.”
The technician’s paper mask failed to conceal her confusion, laced with a hint of disappointment. I smiled back, seeing where she had gone wrong.
“No, no, I’m not quitting, I’m not closing. I just need to go old school. Half these vessels are the size of a porky index finger. I’m hoping that if I can tie a few of them off by hand, it might give me enough space to squeeze in the stapler.”
I risked one more crank on the rib spreader, trying to get as much room for my hands as I dared, fearing I might break a rib by going too far. But the crack of a fracture never came and I set to work, forceps teasing through tissue planes, nudged by the heart, jostled by the lungs, passing suture and cinching down knots. Tie, cut, and do it again, and again, and suddenly the tumor was becoming undone, mobile, and to my way of thinking, vulnerable. I went back to the TA stapler and this time there was enough of a gap for me to squeeze it into normal-looking tissue, fire my staples, and be rid of this thing once and for all.
With the tumor out of the chest I pressed the release mechanism on the device and the pretty little staple line bounced free. No arterial spurt. No red gusher. There was one more test to perform.
“Can I get a couple of liters of sterile saline, please?”
Here, the premise behind my surgical technique is identical to that of a cyclist trying to repair the rubber inner tube of a flat tire. Pour enough warm fluid into the chest to fill it with liquid and submerge the lungs. Wait as the ventilator moves air in and out of the lungs. Observe the staple line for a stream of leaking silver bubbles. I watched and I waited. No bubbles. No bubbles means no leaks, means a perfect, airtight repair.
I placed a chest tube to evacuate the residual air and blocked some nerves adjacent to my incision with local anesthetic, and then this time I really did begin to close.
Stitch by stitch, layer by layer, Helen’s heart receded from view and disappeared. Once she was all zipped up, I placed a comfortable bandage around her chest, gave her a final pat on the head, and she was gone, shipped off to recovery and from there to critical care, destined to go on a happy drug bender for the next few hours. And why not? She had earned it. Under anesthesia Helen had never skipped a beat, literally, her heart rate maintaining a steady rhythm, her blood pressure more in keeping with that of a two-year-old than a teenager. A little indulgence and pampering at Angell’s famous Spa Narcotica would do her a world of good.
This left me alone with the enemy, drowned and lifeless, pickling in its toxic vat of formalin. I held the transparent plastic container up to the light, rotated it back and forth in my hand, and studied the tumor. I liked what I saw. To
my naked eye, the margin looked good, the tumor removed in its entirety. But almost as soon as I acknowledged my optimism, I became doubtful, fearing professional complacency. Sometimes the cure is a done deal but this was not one of those times. As I always tell my clients, my eyes are not microscopes. I forced myself to rein in the celebrations until the final written report came back from the pathologists. And as I watched Helen disappearing on a gurney I was forced to wonder whether the dead creature in my hand was destined to have the last laugh.
WHENEVER I watch animals recover from a major surgery I am struck by their tolerance of what must be a terrifying awakening—trapped in the now, unable to anticipate the benefits of what they must endure. You might think the panic and disorientation would be overwhelming, akin to waking up in a cheap hotel room with blood on the sheets, a gash next to your spine, and only one kidney. Yet, for the most part, our pets edge their way back into a familiar world of human touch and soothing words. We can console, even though we cannot explain. Chemicals may alleviate the pain, but we still rely upon our most fundamental and effective method of communication with our animals, our presence and physical attentiveness to their needs.
Helen’s recovery went well. She didn’t vocalize, flail, or fight. Though her hearing was shot, she could still register the hands stroking her head, tucking her into a blanket, getting her body temperature back into the normal range. Within minutes of her return to full consciousness she was riding a gurney from the recovery area to her new home in the critical care unit.
Unlike hospitalized children, hospitalized pets are not the lucky beneficiaries of mechanically operated beds, a neck-straining television bolted to the ceiling, bad chocolate pudding, and inopportune visits by scary clowns. Somehow they still manage to thrive as they recover from our interventions. Helen was no exception. She remained under Dr. Able’s care and every time I checked in on her she was making remarkable and speedy progress. There was nothing frail or distressed about our ragamuffin spaniel. Though her compact pod in critical care afforded her space to lie down and move around freely, she was often to be found standing at the door to her cage. She would give me a cursory once-over with her eyes as I approached, but I was still the recipient of a curt wiggle of her tail rather than an exuberant wag, as though she were bound more by convention than genuine affection for the man who had reached into her chest and plucked a tumor away from her heart. She sensed my good intentions but I never got the impression she needed to be friends. Ours was a strictly professional relationship and I could understand why. With our greeting over, she would return to checking out the scene, a convict pacing nervously behind the bars, as though waiting for her moment to ask “Do I get out of here today? Did someone post bail?”
Love Is the Best Medicine Page 19