That must be the vaginal wall over there, I thought. And up there, the side of the bladder; behind the bladder, a portion of the rectum and the sacral plexus. And dangling everywhere were the tangled shreds of nerves, vessels, and tendons.
Closure seemed to take forever. There were several layers of tissue that had to be approximated. Then we had to decide how best to close the skin. Should we trim here? Advance there? Tuck this? Excise that?
By the time we placed the last drain and put in the last suture, it was early afternoon. Sarah’s pressure was stable. She had been given eighteen units of blood but had come through the procedure well.
Bill went to talk to the family, and left me to apply the dressings. I peeled away the bloodstained sheets. For a brief moment, after the drapes had been removed and before the nurses had been able to cover her with a fresh gown, Sarah lay totally exposed.
We tried not to stare. All of us—myself, the anesthesiologists, the nurses—quickly found other things for our eyes to do. But the truth was there now, the truth we had tried to hide under all those layers of sterile, blue surgical drapes. Sarah had no leg. There was a long line of black sutures across the left side of her lower abdomen, and below that—nothing.
I applied the dressings, being careful not to disturb the catheter. Sarah’s skin was pale and cold. I lifted the drain reservoirs onto her belly, then we moved her off the operating table and back onto the cart. It wasn’t difficult; she didn’t weigh much anymore. The nurses covered her with warm blankets, and then I wheeled her to the recovery room.
Sarah’s post-op course was stormy. She ran a fever for four days. The inferior portion of her wound dehisced. Her labia swelled so much she couldn’t urinate. I tried to put a catheter back in her, but she was so swollen I couldn’t find the urethra. Finally we had to call a urologist to do it.
But Sarah was a marvel. She kept thanking us for all we were doing, and apologizing “for being such a bother.” She was as bright and engaging as ever. I couldn’t understand it. I thought if I lost my leg I would be inconsolable. I would never laugh again. Like Job’s wife’s I would want to curse God and die.
I longed to ask Sarah about it, but I didn’t know how. What would I say, “Sarah, shouldn’t you be more upset about having your leg chopped off?” Finally I approached Annie Cheevers, Sarah’s nurse. Annie had become like Sarah’s big sister.
“Sure, we talk about it,” Annie told me. “And of course she’s sad about losing her leg, but she says it’s made her realize how many things she hasn’t lost. She says it’s like a millionaire who loses a thousand dollars—he’s sad, but he’s still not that bad off.”
I thanked Annie and nodded thoughtfully, as though I understood, but I still didn’t get it. I was still too ignorant about what a scalpel could, and could not, do. All I could see was that we had taken away her leg. I didn’t yet understand that there are some things no surgeon, no disease, can ever take away.
Annie and the other nurses adored Sarah. The day nurse would come back at night to sit and watch TV with her. The night nurse would stay in the morning to have breakfast with her. The PM shift nurse would call as soon as she got home to be sure she was given her midnight meds. And how they guarded her. Every order, every procedure, was scrutinized.
“Dr. Collins, she just had her hemoglobin checked yesterday. Can’t we wait until tomorrow to check it again?”
“Dr. Collins, I noticed a little serous drainage coming from the bottom of her incision.”
“Dr. Collins, don’t go in now. She just fell asleep. Couldn’t you come back later?”
How thrilled we were three days after surgery when Sarah stood and took a few tentative steps on her crutches. She was pale and trembling as she looked at us for encouragement.
And how shocked I was seven days after surgery when I knocked on her door and heard Annie Cheever’s voice tell me to “wait just a minute.” I stood at the door, looking at the curtain that had been drawn around the bed, thinking Sarah must be on the bedpan. But why the bedpan? She had been walking to the bathroom for several days now. Finally Annie pulled back the curtain, gestured dramatically at Sarah, and said, “Ta-da!”
Sarah was sitting on the edge of the bed smiling at me. Annie had helped her wash and set her hair and apply her makeup. She was stunning. I stared at her, a myriad of emotions swirling inside me.
Annie began to laugh. “I think he likes it, Sarah.”
“Sarah,” I said, “you look…nice.” It was my turn to blush.
Annie was outraged. “Nice? That’s all you can say? That she looks nice?”
“I, uh, well you look really nice. I mean—”
They both laughed. They knew they had succeeded.
Sarah went home a few days later. She gave me a big hug and thanked me for saving her. I looked away and said nothing. I saw her two weeks later when she returned to Rochester for a post-op visit. After that I moved to another service. But for months afterward I would see the black suture line running across the stump of Sarah’s left pelvis; and I would wonder just what it was Sarah thought she hadn’t lost.
But I was busy with other things, other patients, and soon I stopped thinking of Sarah at all.
Chapter Twenty-Seven
October
On September 29 I left Bill Kramer’s orthopedic oncology service and was assigned to adult reconstructive surgery with Dr. Frank Satterfield. I had learned a lot from Bill, but I was happy to get away from cancer and get back to hip replacements and fractures.
I had been on Frank Satterfield’s service for three weeks. We were just finishing Mr. Schaeffer’s total hip surgery. Frank stepped back, snapped off his gloves, and told me to close.
“Nice job today, Mike,” he said. “I think you’re ready. The next one is yours.”
The next one was mine.
I had never done a total hip replacement before. I had been assisting on them for two years now. Attendings had let me do parts of the procedure, but I had never done the whole thing myself. Being the assistant had become routine, almost boring, and I had been yearning for the chance to do it all.
But now that my time had come I was scared stiff. Total hip replacement was a complex, almost daunting procedure. The incision had to be in just the right place, then the fascia had to be incised, and the abductor muscles released—just enough, but not too much. Then the capsulotomy, and the osteotomy of the femoral neck at precisely the right distance above the lesser trochanter. Then the reaming of the acetabulum and the proper positioning of the cup. Then the reaming of the femoral canal, and the choosing of the correct stem size and length. Then the cementing, and the placing of the femoral prosthesis in just the correct amount of anteversion. Then the selecting of neck length, and finally the closure, being sure to get the capsule closed and the abductors repaired and the fascia approximated. And if everything was done correctly, if the approach and the implant selection and the cementing and the orientation and the repair were all done just right—you would have a happy patient with a painless hip.
But there were pitfalls everywhere. Damage the sciatic nerve, and the patient could be partially paralyzed. Mal-orient the components, and the hip could dislocate. Cut the femoral artery, and the patient could bleed to death. Over-ream the acetabulum, and you could break through the wall of the pelvis. Impact the stem too vigorously, and you could fracture the femur. Kink the femoral vein, and the patient could die of a pulmonary embolus. Repair the abductors improperly, and the patient could limp for the rest of his life. Rush the cementing, and the prosthesis could loosen prematurely. Take too long with the cementing, and the patient could go hypotensive and die on the table. Break your sterile technique, and the hip could get infected. Fail to evaluate the medical condition, and the patient could die of a heart attack. Give the wrong anesthetic, and the patient could become a vegetable.
And all the time you are doing this, you are living with the realization that a mistake could ruin your career. Screw up once, blow some b
ig operation, and no attending in his right mind would ever let you operate again.
You get your chance. The attending hands you the ball. If you run with it, if you do a good job, then you are on your way, your reputation is made. But if you drop the ball, if you screw up with your first chance, there might never be a second one.
“See one. Do one. Teach one.” That was the way we jokingly described the learning process when I was at the Veterans Administration Hospital in medical school. But this was the Mayo Clinic and residents were very heavily scrutinized before they were allowed to operate. I was being given my chance, and I wasn’t going to blow it.
I checked with Amy, Dr. Satterfield’s secretary. She told me our next total hip was scheduled for the following Monday. That would give me the weekend to go over the procedure, step by step, being sure I had it all down.
I pulled the X-rays for the case and templated them, planning which size prostheses I would use. I poured over Campbell’s Operative Orthopedics, and Charnley’s Low Friction Arthroplasty of the Hip. I went over all the pertinent articles in the Journal of Bone and Joint Surgery. I reviewed the anatomy in Hollinshead’s Anatomy for Surgeons. I even called Jack Manning who had gotten to do his first total hip the quarter before.
“Try not to cement the femoral component upside down,” Jack told me.
“You’re a big help.”
“Relax, Mike. You’ve probably scrubbed on a hundred hips. You’ve done parts of this operation plenty of times. The only difference is this time you’re going to do them all. Hell, I watched you do that subtroch fracture last month. You looked like you had been doing them your whole life. Those are a hell of a lot harder cases than total hips.”
On Monday morning I was at the hospital early. I finished rounds in time to go over my notes on the surgical technique one more time. The hip replacement was our first case. Steve DeBurke, the junior resident, helped me get the patient prepped and draped. Then we sent word to Dr. Satterfield in the surgeons’ lounge that we were ready. While Frank scrubbed in, I got the marking pen and outlined the incision. This was my subtle way of reminding him that he had promised this case to me.
When he was gowned and gloved, he approached the operative field and said to me, “You ready?”
“Yes, sir.”
“Then let’s go,” he said, gesturing at the patient. “We’re wasting time.”
Once I was into the case I was surprised at how smoothly it all went. I had the operation down cold, and was too focused to be nervous. When the femoral component had been cemented and the hip reduced, Frank stepped back from the table. He had hardly said a word the entire case but I was glad he had been there. It was reassuring to know he could help if I ran into any problems.
“Pretty damn good job,” he said to me.
“Thanks, Dr. Satterfield,” I said.
He shucked off his surgical gown and said, “I’ll be in Room Four doing the knee scope. You guys finish up in here and get the next one going.”
When he had gone I finished repairing the abductors and the capsule, then turned to Steve. “You know what this means, don’t you?” I said, stepping back and motioning to him to assume the head surgeon’s position.
Steve’s eyes lit up and I could tell behind his mask he was grinning like a little kid. “I was hoping you wouldn’t forget,” he said.
There was an unwritten rule among the residents that if the senior resident got to do the case, the junior resident got to do the closure. I had watched Steve assist, and though he was a little too raw to do the abductor repair, I was sure he could handle the rest of the closure. Of course it took him ten minutes longer than it would have taken me, but he had fun doing it and I had fun helping him.
And when we had finished the day, when we had changed out of our scrubs and into our street clothes, and completed afternoon rounds, I realized something was different. I was no longer just a student. That’s what residents are, in a sense, students. They are still learning. Well, I had done a total hip that day—by myself. And I could plate an ankle, scope a knee, and fix a both-bone forearm fracture, too. Hell, in a pinch I could probably do a rotator cuff repair, although I didn’t feel too sure about that.
I felt a growing confidence, a feeling that all these years of work were starting to pay off. Four years of high school, and four years of college, and four years of medical school, and a year of internship, and two years of ortho with two more to go. That’s seventeen years. Sometimes it seemed like I would never be done, that I would be a student forever. But after today I knew that wasn’t true, for the first time I didn’t feel like a student. I felt like a surgeon.
Chapter Twenty-Eight
December
I was halfway through my third year when I realized I might have a chance to be named chief resident. The selection wouldn’t be made for another few months, but I knew the last two and a half years of intense study were paying off. Instead of hiding at every conference, I found myself answering questions, even making suggestions. “Why, you’re no stupider than the rest of us,” Frank had said to me recently.
What made it easy was that I loved what I was doing. I loved seeing patients and I loved doing surgery. In the operating room I was becoming more comfortable. Besides having done a total hip, I had removed a torn cartilage through an arthroscope, and had released a carpal tunnel. I had rodded a femur, plated a tibia, and wired an ulna.
It was heady stuff, and I was proud of what I had achieved. But to be appointed chief resident I would have to do more than just survive the next few months. I would have to shine.
Patti went into labor with our third child, Patrick, three weeks before Christmas. She started feeling contractions one morning around six, just as I was leaving for work. She asked me to wait five minutes, then five more.
Finally, after a particularly strong contraction, she said, “I think it’s time. We’d better go to the hospital now.”
I paged Dr. Satterfield and told him Patti was having her baby. He told me I could take the whole day off. “Let me know if it’s a boy or a girl,” he said.
I bundled up the kids, took them out to the car, and got them in their car seats. Then I went back inside and helped Patti. We dropped the kids at Alice Chapin’s and headed to Methodist Hospital. By seven, when she was admitted to the OB floor, Patti’s contractions were four minutes apart and getting stronger. By eight she was fully dilated.
“You don’t waste any time, do you?” said the nurse who wheeled her into the delivery room.
Five minutes later Bill Chapin and Frank Wales, holding surgical masks over their faces, showed up. They had been waiting to start a case down in the OR when Alice Chapin called Bill and told him Patti was in labor. They came to say hi.
“Mike,” Bill said. “How ya doin’? How’d that tibial plateau fracture go yesterday?” Then, almost as an afterthought, he looked at Patti who was by then up in stirrups. “Oh, hi, Patti,” he said. “You’re doing fine. Just keep pushing.”
Patti was well into her labor pains and couldn’t care less that two of her husband’s friends were watching her deliver. Patrick was born a few minutes later.
“Angry-looking little critter, isn’t he?” Frank asked as he watched Patrick scream and squirm.
“Well, it’s been fun,” Bill said, after the baby had been cleaned and suctioned. “We gotta go. Duty calls.” He turned to Kenny Billings, Patti’s obstetrician, who was delivering the placenta. “Nice job, Kenny,” he said. “Now don’t forget the lidocaine when you sew her up.”
Patti pushed herself up on her elbows. “Will you two get out of here?”
Frank looked at Bill. “I reckon she means us.” He shook his head sadly. “It must be the drugs talking.”
As they turned to go, Bill said, “Don’t worry, Patti, we’ll be by later this morning with coffee and donuts—hopefully in time for Jeopardy.”
“I can hardly wait.”
During the next two days there was a steady stream of reside
nts in and out of Patti’s room. The nurses found it difficult to enforce the visitation rules since almost every visitor was a doctor. Patti told me at one time there were four doctors, two of their wives, the mother of one of Patti’s college roommates, a nurse, and Patrick in her room at the same time. She took it all in stride. She would grab Patrick from the arms of one of the residents, throw a blanket over her chest, and “plug him in,” as she called breast-feeding.
She came home on Saturday. There were so many flowers that we filled the backseat of the car with them. When we got home, Sue Manning, who had come over to watch Eileen and Mary Kate, helped me bring in the flowers. Then she kissed Patti. “Gotta run,” she said. “I’ll be back this afternoon.” She gave me a peck on the cheek and told me Patti needed peace and quiet. “Peace,” she repeated, staring intently at me. “And quiet.”
What was that supposed to mean? Did she think I was going to attack Patti that afternoon?
“I thought I’d give you at least ’til tomorrow,” I said to Patti later, when I told her of Sue’s warning.
“It would be your last act on this earth,” Patti said.
“Fine. Have it your way. You’ll come crawling to me in a day or two.”
She held her hands low across her abdomen. “Don’t make me laugh,” she pleaded.
On Monday I tried to get home as early as I could. I came in the back door about six and hung my coat on the back of a chair.
“How are you, hon?” I asked as Patti turned from the sink.
“I am so glad you’re home,” she said, drying her hands and giving me a hug.
“Me, too.” We stood there holding each other, her head against my chest. “Where are the kids?” I asked.
“Playing in the basement.”
I started to pull away, to call them.
“Don’t,” she said, still clinging to me. “Just let me stay here for a minute before they come up.”
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