“I was,” I said, having no illusions about how ignorant I had been just one year before.
“Yeah, I forgot. Collins, you were among the orthopedically brain dead a year ago. In fact, for a while, I think BJ Burke had you on the endangered species list. Only through the diligent efforts of Drs. Wales, Manning, and I have you started to resemble a real orthopod.”
“Excuse me, but was I the resident who called the peroneal nerve the pudendal nerve?” The peroneal nerve goes to the leg. The pudendal nerve goes to the genitals. Bill had made a terrible gaffe at fracture conference last September and we had been ribbing him ever since, constantly inquiring as to the health, activity, and function of his pudendal nerve.
“For Chrissake,” he muttered, “a guy makes one little mistake and his friends never let him forget it.”
My first assignment of my second year was with Dr. Matt Wilk, one of Mayo’s premier hand surgeons. I had been on his service for about a month when I was called to the ER to see Jason Withers, a thirty-six-year-old carpenter who had cut off all four fingers of his right hand while using a circular saw. His coworkers had enough sense to pick up the fingers, stick them in a Baggie, and put them on ice. I examined the fingers. They all looked pretty good except for the index finger, which had most of the skin and soft tissue stripped away.
I gave Jason some morphine, cultured his wounds, and started some antibiotics. Then I sent him for X-rays. I had the four amputated fingers X-rayed as well.
While we were waiting for the X-rays to come back I began talking to Jason. He was married, with two boys aged four and five.
“Doc,” he said, chewing his lower lip and trying not to cry, “my hand is gone. What am I going to do? I’m a carpenter. I can’t work with one hand.”
I felt Jason’s situation keenly. I, too, was a father with young kids. I, too, depended on my hands to make a living.
“Is there something you guys can do?” Jason asked, his eyes welling with tears. “Can you put my fingers back on?”
That was a tough call. The lacerations seemed fairly sharp. The wounds didn’t appear to be grossly contaminated—but four fingers? That was a tall order.
The X-rays were back in ten minutes. They showed the amputation had cut across the base of the proximal phalanges of all four fingers.
I knew that not all amputated fingers could or should be reattached, but Jason seemed like a good candidate: he was young, his occupation demanded use of his hand, the injury was to his dominant hand. There was one other factor to consider, however.
“You don’t smoke do you, Jason?” I asked.
“Yeah, I do.”
“About how much?”
“Pack and a half, maybe two packs a day.”
That complicated things. Dr. Wilk hated doing replants on smokers. The failure rate for smokers was markedly higher than the failure rate for nonsmokers. “I’m damned if I’m going to stay up all night replanting some guy’s hand if he’s going to turn around and wreck it all by smoking,” Matt had said on more than one occasion.
“You gotta help me, Doc,” Jason said. “I gotta be able to work.”
This was going to be a tough sell to Dr. Wilk.
“Jason, do you think you could quit smoking?”
“Quit smoking? Yeah, I guess so, why?”
“Well, first of all because smoking is about the worst thing a man can do to his body. Second, smoking constricts blood vessels. That means if your fingers aren’t too badly damaged, and if we are able to reattach them, and if we can get adequate blood flow to them, then all that would go down the drain if you smoked—even one cigarette. The vessels would constrict and the fingers would die.”
Jason struggled to sit up in his cart. He leaned forward, reached into his shirt pocket with his left hand, took out a package of Camels, and threw them on the floor. “Doc, if you guys can put my fingers back on, I’ll never smoke again, not a single cigarette. Ever.”
I called Dr. Wilk and laid out the scenario for him.
“All four fingers, huh?” He thought for a moment. “Clean amputations?” he asked.
“Yeah, pretty clean.”
“How long has it been since the injury occurred?” he asked.
“Two hours. And the fingers have been on ice the whole time.” I was trying to convince him that we should try to replant Jason’s fingers.
Dr. Wilk paused for a moment. “Sounds like a good candidate for a replant. He’s not a smoker, is he?”
“Well, yeah, but he says he will quit. He says he will never take another puff.”
“That’s what they all say.”
He remained silent until I couldn’t stand it any longer.
“He’s a carpenter, Dr. Wilk, and it’s his dominant hand.”
Still no response. Why was he being so hard-nosed?
“Sir, he’s got two little kids.”
“So you think we should go ahead with the replant?”
“Yes, sir. Maybe not the index finger, that looks pretty chewed up. But I think we should do the other three.”
“And you believe this guy when he says he won’t smoke?”
“Yes, sir. I do.”
He sighed. “All right. Call the OR and let me know when they’re ready.”
I went back to talk to Jason. His wife had gotten there by then. I introduced myself to her. “Good news,” I told them. “I talked to Dr. Wilk who is one of the world’s best replant surgeons. He thinks we should try to reattach your fingers.”
“Thank God,” Jason said.
“Jason, don’t get your hopes up too high. First of all, one of your fingers looks too bad to save. And with the other three, even if we reattach them there is no guarantee they will survive. And even if they do survive, your fingers will never be the same. They’ll never work as well as they used to.”
“I know, Doc. But you guys just get those fingers back on for me. I’ll make ’em work.”
“There is one more thing,” I said. “You have to stop smoking.” I shifted my gaze from Jason to his wife. “If he smokes, he will ruin everything. His fingers will die.”
“Don’t worry, Doc. If you guys can put my fingers back on I won’t ever look at a cigarette again.”
Like all replant procedures, the operation took forever. The two of us, microsurgical tools in our hands, were hunched over the operating microscope for six hours. The index finger was too badly damaged to replant, but we were able to save the other three. We anastomosed the digital vessels and nerves, repaired the tendons, and fixed the bones.
It was touch and go for the first three days. His fingers looked dark and dusky. It was hard to tell if they were going to survive. Every morning and every afternoon I would unwrap the white gauze dressings and check the fingers. They didn’t look terrible, but they didn’t look good.
On the morning of the fourth day, things changed. For the first time, his fingers looked a little pinker, a little healthier. On the fifth day there was no doubt: the replants were working.
Jason and his wife were thrilled. Even their untrained eyes could see the difference. With each succeeding day the fingers continued to improve. Even the therapists were amazed.
Jason went home on the tenth day after surgery. We had arranged for outpatient therapy and planned to see him back in the office in one week.
The day after he was discharged I got a frantic call from his wife. “Something happened,” she said. “His fingers look awful. You have to check him right away.”
I told her to bring Jason straight to the emergency room. I was waiting when they arrived. Jason’s wife was right. The fingers were cold and almost black.
I was sick. “Jason,” I said, “I’m so sorry. I don’t know what could have happened. Something has gone wrong.”
Jason didn’t respond, nor did he look at me. He set his mouth in a line and stared at the ground. He looked almost guilty. A thought occurred to me.
It couldn’t be, I thought. He wouldn’t have been that big an idiot.
“Jason,” I said, “you didn’t smoke did you?”
He wouldn’t answer.
I winced and shook my head in disbelief. “Oh, Jason,” I said, unable to hide the disappointment and disgust I felt. It was all I could do to keep from saying, “You fucking moron.”
I looked at Jason and his wife. We all knew what this meant.
“Is there anything you can do?” his wife asked.
I let out a long sigh. “I’ll call Dr. Wilk. We’ll have to take him back to the operating room.”
She brightened slightly. “To redo the operation?”
I shook my head. “No,” I said, “to see if there is anything that can be saved.”
I dreaded the call to Dr. Wilk. He hadn’t wanted to do the operation in the first place. I had talked him into it. I had assured him that Jason would quit smoking. All the hours of work, all the thousands of dollars expended, all our care and worry had been a waste. Jason had stuck the knife in his own back—just as Dr. Wilk suspected he would.
I couldn’t believe it. I just couldn’t believe it. I would have done anything for Jason. When I first met him I was so upset that he had lost his fingers that I would have given him one of my own. I had poured my heart and soul into his care. I had fretted over every little thing, trying so desperately to make the operation a success.
And the stupid idiot had ruined it all.
The more I thought of it, the angrier I became. What kind of selfdestructive fool was he? Hadn’t I told him fifty times not to have even one single puff? Hadn’t I warned him what would happen? But he had to have his smoke, didn’t he? I talked the best replant surgeon in the world into reattaching his fingers and then Jason blew it all.
Over the course of the next ten days, we brought Jason back to the OR three times, each time whittling away more and more of the necrotic tissue on his fingers until, finally, only stumps remained.
Dr. Wilk never said much. I kept waiting for the hammer to fall, waiting for him to let me know what a fool I had been, how I had wasted his and everyone else’s time by insisting we reattach Jason’s fingers.
I continued to see Jason twice a day, seething each time I went into his room, changing his dressings in a cold fury. I went to bat for you, my attitude said, and you betrayed me.
Finally Dr. Wilk took me aside.
Well, here it comes, I thought, the ream job of the century.
“Mike,” he said, “show me your right hand.”
Puzzled, I held it out to him.
“How many fingers do you have there?”
“How many…? Ah, four. Well, five, with my thumb.”
“How many does Jason have?”
“None. Just his thumb.”
“Then why don’t you quit acting like you are the victim? Why don’t you get off your high horse and start acting like a doctor, not a judge? All right, Jason did a stupid thing, but does that mean our responsibility to him is over? Do surgeons only have obligations to smart patients? Jason not only has to live without a right hand, he has to live with the knowledge that it was his own stupidity that caused it. Give the guy a break. He’s suffered enough.”
I gave a servile nod of the head, just as residents are supposed to do. But it took me a while to understand what Dr. Wilk had been trying to tell me. Surgeons can become too focused on surgery, too involved in the mechanics of the things they do for patients. The patient comes into our hospital, has our surgery, and follows our instructions. Is it any wonder that we fall into the trap of thinking that their injury is actually our injury, of wanting the patient not to get in the way of the management of our problem?
It’s not about the problem, and it’s not about the surgeon, Dr. Wilk was telling me. It’s about a human being who needs our help, not our judgment.
I wasn’t sure what to say to Jason. When I changed his dressing the following morning I told him I was sorry things had turned out the way they did.
“And I’m sorry for not being more understanding,” I said to him. “I know you wouldn’t have smoked if you knew what was going to happen.”
Jason didn’t reply for a while, then in a low voice he said, “I know it doesn’t matter now. I know I’m a fucking cripple for life, but…” He set his jaw and gave me a fierce, determined look. “I’m going to quit smoking. I’ll never have another goddamn cigarette for the rest of my life.”
Too little, too late? I didn’t think so. It was a start. There would be time to deal with the self-pity and self-loathing later. We would start occupational therapy. We would arrange for vocational rehab. It was too late to get his hand back, but we could still help him get a life.
“That’s a good first step, Jason,” I said.
Chapter Seventeen
August
Sometimes the life of a junior resident got to be too much. At 6:45 one Tuesday morning, Jack Manning looked up from the sports section of the Post-Bulletin. “You know,” he said, “this sucks.” He closed the paper and slid it away from him. “This whole thing sucks.”
“You talking about the French toast?” Bill asked.
“No, asshole. I mean this.” He looked around the room, waving his hands at everything and nothing. “All this bullshit we have to go through.” He set his dirty glasses on the table and rubbed his bloodshot eyes. “I was up the whole damn night—”
A chorus of sarcastic “Ooohhhs” arose from the rest of the table. “Poor baby,” Bill said. Jack was talking to the wrong crowd if he wanted sympathy.
Jack ignored the interruption. “I didn’t even get to see my bed. I was up all night doing stupid shit any janitor could have done.” He reached over and took the cup of coffee from Bill’s tray.
“And it wouldn’t be so bad if I was doing something worthwhile, but all I did was narc rounds and start about ten IVs, then go sew up some drunken biker dude’s leg. The dumb shit drove through the front window of the flower shop across the street. Never even slowed down. When the cops got there his bike was still running and he was passed out in a pile of carnations with his leg bleeding like stink. The whole floor was covered with blood. His hemoglobin was eight when we got him in the ER.
“And the whole time I’m sewing up his leg, he’s telling me what a pussy I am and how he’s gonna kick my ass as soon as we let him out of restraints, which, if I have my way, will be in about six years.” He sighed and took a tentative sip of the coffee he was holding in both hands.
“Then I got stuck babysitting one of Hale’s patients who kept saying that her pain was so bad it was like a million atom bombs exploding in her vagina.”
Bill coughed up a mouthful of orange juice. “So, Dr. Freud, did you explore the implications of this metaphor with her?”
“It wasn’t a metaphor. It was a simile, and no I didn’t. She said she was going insane and she wanted me to call Hale at home and get him to come in.”
“Yeah, he’da loved that,” Bill said, reaching for the crumpled sports section.
“Who’s got atom bombs in her vagina?” Frank asked, putting his tray down and squeezing in with us.
“Don’t ask,” Bill said. “Manning is rambling on about his night on call.”
Jack ignored the interruption. “Then,” he said, “some lady up on Seven had chest pain…” He hung his head and shook it wearily. “And every ten minutes someone else would call me to go start another IV. Hell, I musta started ten of ’em.”
“Yeah, yeah. You already told us that,” Bill said, without looking up from the paper.
“And you know what else I’m sick of?” Jack asked. “I’m sick of having all the patients think that I am nothing but a fucking spear carrier for the almighty attending. I do all the work. I admit ’em. I do the H&P. I start their IV when no one else can. I do every lousy job in the book. And every single person in this hospital thinks I’m shit—attendings, nurses, patients, all of them.
“Well, the next time one of the nurses calls me I’m going to admit I’m shit. I’ll just walk in the patient�
�s room and introduce myself. ‘Howdy, ma’am, I’m here to start your IV. I have to do it because Dr. Farthingham, your real doctor, is out playing golf. I do all the shit jobs.’
“And she’ll say, ‘What is your name, tall stranger?’
“And I’ll look her right in the eye and say, ‘Shit. Joe Shit. At your service, ma’am.’
“But I won’t get discouraged. I’ll work and I’ll slave. I’ll do all those jobs no one else will do. And someday, somehow, I’ll finish my residency, and I’ll open a posh practice in Manhattan with scribbly paintings and Navajo rugs on the wall. And I’ll hire some supermodel as a receptionist. Of course I’ll have to change my name. Joe Shit won’t cut it in Manhattan. I’ll get a goldplated sign outside my paneled door: Joseph Faeces, MD.”
Bill yawned. “Yeah, that’s great, Jack, or Joe, or whatever your name is. I’ll be sure to send lots of patients to you.”
Conversation continued at the tables around us, but we were silent until Jack started up again.
“I’m telling you, this sucks.”
No one cared. What was the point of talking about it? Nothing was going to change. We just had to deal with it. Complaining didn’t help.
Jack slammed Bill’s now-empty coffee cup on the table. “Listen,” he said, “we don’t have to put up with this shit. We can change our residency. After all, who knows more about residencies than residents? We can go to the Clinic and demand they look into this.”
The rest of us shifted in our seats and looked at each other. What was Jack’s problem? There’s good and bad in everything, and things here weren’t that bad. It sure wasn’t worth starting some big revolt. And Jack seemed like that last guy you would pick to be a rabble-rousing agitator. He just had a bad night on call, that’s all.
“I want to know that you guys support me,” he said. “I want to go to BJ and give him a list of demands. I want to tell him how this residency should be run.”
“What are you going to do for a living after BJ fires your ass?” Bill said.
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