Open Heart

by A. B. Yehoshua

  Lazar was sitting with his two assistants next to his big desk. He didn’t seem to have lost any weight in the interim, but he did look rather pale. With a quick, friendly gesture, he immediately beckoned me to come closer and said in surprise, “But you were supposed to come back on the fifteenth of the month. What made you change your plans?” I was so astonished to see that there was room in his bureaucratic brain for something as minor as the date of my return from England, a resident of uncertain status at the hospital like me, that I was unable to make up a lie on the spot, and blushing furiously, in front of everybody, I blurted out the truth, which burst out of me with uncontrollable force: “I just wanted to be here for your operation. And tomorrow I’m going to help Dr. Nakash with the anesthesia.” With this I succeeded in surprising even the unsurprisable Lazar. “You came back especially for my operation?” He turned in amazement to his assistants, who were also suitably surprised at my generous concern. After he recovered he said, “I see that the entire medical staff of the hospital wants to be in on the show. It’s a pity they’re not operating on me on the stage of the big auditorium.” He burst into loud laughter, in which he was joined by me and the two assistants, while his secretary only smiled quietly and somewhat mysteriously. But Lazar soon cut the entertainment short with a wave of his hand in my direction, and I left the room.

  Before leaving Lazar’s secretary, I asked her how Dori was taking it. As I had expected, she was tense and even more confused than her husband. And soon she would be arriving to spend the night with him in a special room which had been put at their disposal for the first night of his hospitalization. The thought that she couldn’t spend even one night alone in her own home and her own bed sent a wave of pleasurable pity surging through me. I was so moved that for a moment I even thought of waiting for her right there in the office, but I was afraid that if she heard the reason for my return from England she would ask Professor Hishin to take me off the operating team, so I removed myself from the scene—but not entirely. In the depths of a side corridor I sat hidden in the growing darkness, waiting for the sound of her brisk, confident steps.

  During the six hours of the operation she and her son sat in her husband’s office, with his faithful secretary pressing food and drink on them all the time. The granny came from the old-age home to be with the family and give them the support of her natural optimism and experience of life. Hishin and Levine themselves took Lazar down from the ward to the surgical wing at two o’clock in the afternoon, apparently relishing the role of simple stretcher-bearers.

  Although Lazar was already dazed and sedated, he had to smile weakly at the constant stream of jokes and witticisms showered on him by Hishin. Professor Levine, in contrast, looked grave and solemn. Perhaps he was silently brewing up the next psychotic outburst, which would save him from his anger. Because of the number of instruments crowding the room for heart operations, the initial “takeoff” was performed in a small induction room where Dr. Nakash and Dr. Yarden were already waiting for the hospital director, and I too was standing in a corner. Yes, it was already clear to me that this would be my place throughout the operation, standing in a remote corner, for apart from the two technicians in charge of the cardiopulmonary bypass machine, and the three nurses, and Professor Adler himself, who was still standing at the basin and washing his hands with compulsive thoroughness, Hishin and Levine would be watching every move with gimlet eyes. In an operation of this nature it was necessary to maintain close communication between the surgeon and the anesthetists, and after the “takeoff” they had been instructed to maintain the “flight” by using a Fentanyl drip, a short-action anesthetic that could be precisely controlled, as opposed to anesthetic gases, whose action was more general and erratic. Nakash just had time to explain this change of plan to me before Lazar was brought in, but the moment his bed was rolled into the room, I noticed something about Nakash that I had never seen before: his hands were trembling slightly. After he had begun to inject the cocktails he had prepared into the two intravenous lines in the wrist, when it was time to insert the tube into the lungs, I saw that he, the most skillful and precise of anesthetists, suddenly missed the exact spot where the tube should have been inserted, and the dazed but not yet unconscious Lazar jerked under Nakash’s dark hand as if he wanted to bite it. Nakash went pale, and was obliged to apply force to Lazar’s face in order to regain control. It then transpired that the tube had been inserted too deeply so that only one lung was being respirated, and it had to be brought up to above the bifurcation point so that both lungs would be respirated equally. In contrast to Nakash’s uncharacteristic agitation, which heightened my anxiety, the second anesthetist, Dr. Yarden, experienced in cardiac surgery, behaved with calm and impeccable professionalism. He immediately bent over Lazar’s right leg to insert an extra intravenous line in case there was an urgent need for blood or fluids if something went wrong. All of a sudden Lazar’s genitals were exposed to everyone standing in the room. I bowed my head in a sorrowful gesture of respect, but I went on looking out of the corner of my eye at the administrative director’s large penis lying there calmly and full of dignity, with no idea that one of the people present had dared to contend with him in the name of an impossible love. After first cleaning the area with Betadine, Dr. Yarden inserted the long, thin catheter into the penis; then he spread a blue, sterile towel over the entire area in order to protect it from the large syringe being inserted into the femoral vein to provide the extra intravenous line.

  It was new to me that in complex surgery of this kind auxiliary sites were prepared in various places in the body in order to infuse emergency drugs and fluids. Nakash, who had completely recovered by now, prepared himself to insert a central venous line through the jugular vein into the right atrium of the heart. Hishin, who was watching all these preparations with interest, hesitantly offered to do it, but Nakash, intent on regaining his honor after the slip he had made with the tube, insisted on doing it himself and began to spread the blue sterile towels over the entire chest area of the patient, who was already being ventilated. He put on gloves and with the decisiveness of a surgeon inserted the venous line quickly and efficiently. Then he threw the bloodstained gloves into the bin and indicated to Hishin and Levine, who were watching him as fascinatedly as first-year medical students, that they could take Lazar into the operating room. “Come and hold the ambo, Benjy,” Nakash called to me, the way you call to a child when you want to give him something to do, not only to let me know that he hadn’t forgotten me but presumably also to justify my presence to the other anesthetist. I immediately began walking behind the bed as it was wheeled into the other room, squeezing the blue ambo between my hands to pump oxygen into Lazar’s lungs until he was connected to the respirator next to the operating table. At this table the “ideal” surgeon, Professor Adler, was waiting, wrapped in a sterile gown and wearing a headlamp attached to an electric cable that supplied a special beam of light to help him see through the long, narrow binocular lenses he favored, perhaps because his specialty was correcting congenital heart defects in premature babies. In the argot of the surgical wing this specialty was considered the “penthouse” of cardiac surgery, and even a surgeon as arrogant as Hishin showed respect for the delicate skills required to correct the mistakes and negligence of the Creator Himself. But the patient lying in front of Professor Adler now was not a premature baby with a tiny defective heart but a large and important man, the administrative director of the hospital, who required a very routine operation of three bypasses, two venous and one of the left mammary artery. Thus Professor Hishin, who had apparently decided to do the job of the nurse as well, was swabbing his friend’s naked body with Betadine of an almost yolkish consistency, in order to guarantee the sterility that was so essential, before proceeding to make an incision along his leg so the surgeon could extract the long vein which would be cut up to form the bypasses.

  The proud and patronizing Professor Hishin, wonder of wonders, seemed not only
willing but even happy to act as the junior surgeon to his Jerusalem friend, to whom he and Professor Levine referred by his nickname, Bouma. But Bouma himself didn’t seem to be particularly happy with the two professors eager to carry out his orders. If anything, he seemed a little pressured by the crowded succession of tasks imposed on him here. In his department in Jerusalem a master surgeon like himself usually arrived two or three hours after the operation began, after the intensive preparatory work had already been done by assistants and residents while he watched and supervised them on a special television screen installed in his room. When he finally descended to the operating room, he found the chest already opened, the internal mammary artery detached and clamped at its lower end, and the vein destined to become an artery already immersed in its softening solution, ready for cutting. Accordingly, there was nothing left for a head surgeon like himself to do but clamp the aortic outlet from the heart and attach two suction tubes to the inferior vena cava, and then to connect the tubes of the cardiopulmonary bypass machine, say “Bypass on,” and warn the two technicians to be ready to drive the entire blood circulation through the wheels of their machine, so that he could begin to work on the still, moist heart. But here he had to attend to the tedious work of preparation too, which there was no doubt he could do in the best possible way but which he hadn’t done for a long time. Hishin, who was well aware of the situation, constantly tried to make jokes in order to make the time pass more pleasantly for his friend and prevent him from feeling too exploited. Was he also going to get a special fee from the Lazar family? I wondered. Or would he forgo his fee, like me, in favor of other benefits? To this question I could get no answer, certainly not from Professor Levine, who as an internist par excellence had taken up his position in a more spiritual place, next to the anesthetists. They had hung a sheet between Lazar’s face and chest, taped his eyes, and immobilized his neck, gradually decreasing his blood pressure and maintaining a deep and stable sleep in anticipation of the most painful moment of all—the moment when the chest was opened with an electric saw, an operation performed by the Jerusalem wizard with such stunning speed and aplomb that Hishin could not resist a cry of “Bravo!” to which his old friend responded with a faint smile as he bent down to peer at the expressionless face of his patient, whose deep sleep, judging by the stability of the graphs and parameters flickering on the instruments around us, had not been disturbed by the terrible sawing.

  Although I was standing very close to Professor Levine, he stubbornly ignored me, as if from the moment I had decided not to go back and be “examined” by him about what had happened in India he had written me off as a moral failure. But knowing as I did that in spite of his mental problems and other shortcomings he was still one of the most thoughtful and intelligent physicians in the hospital, I kept a close watch on his expression, which was stern and grave, as if what was going to happen here filled him with profound concern. Did all this concern stem from the fact that he was an internist, I asked myself, and it was a long time since he had seen the inside of an operating room? Maybe he was worried about his next psychiatric leave, which he was getting ready to take and which his friend Lazar would have to authorize after he woke up, a long time from now. Then the two anesthetists, Dr. Nakash and Dr. Yarden, began to get ready for the second “takeoff,” this time into outer space: no longer detaching the body from the spirit, but detaching the body from itself and handing it over to the machine with its five pumps and its gleaming bronze wheels. The three technicians, who had inserted all the tubes into their proper places and who had up to now been running the machine on saline, were ready and eager to receive Lazar’s blood from the head surgeon—who began muttering orders to them from behind his mask and binoculars, which all three of them repeated aloud—and to take over the functions of the heart and lungs: pumping, purifying, cleansing, oxygenating, and returning the blood to the body in the right amounts, together with cardioplegia to paralyze the heart. At this moment I saw Levine raising his eyes to the screen in the corner of the ceiling, where he could see Lazar’s pulse monitor as a flat, even, horizontal line without any fluctuations, while the systolic and diastolic blood pressure values were equal owing to the uniform action of the silent machine. And then I felt that I could no longer control the excitement surging inside me, and not like an experienced resident doctor but like an inquisitive greenhorn, I tiptoed over to Hishin—who had just finished suturing Lazar’s leg and was now standing on a little platform to watch the surgeon deftly implanting the bypasses, and who appeared very satisfied with the way things were going—and asked him if I could join him in watching the master surgeon at work so that I could learn something more, for who knew as well as Hishin did that even if I had been banished from surgery into the exile of anesthesiology, my true and eternal desire was and always would be to get my hands inside the human body? “Of course,” he replied immediately and made room for me next to him, to give me a good vantage point. And then, in the middle of the steel frame holding the gaping chest like an open book, I suddenly saw, in its entirety, the still heart of Lazar, and for a moment the pain of my impossible love opposite the silenced love of this strong heart pierced my own.

  Fifteen

  Very close, yet far away, the brown statuette stands on the little table next to our bed. Can we address our complaints to it? What is it but a bit of inorganic matter torn from nature, lacking any will of its own, indifferent to its painstakingly sculpted human appearance? For the little clay hand flung out toward us is not only incapable of touching us, it can’t even let itself drop back into place. And despite the faint, mysterious, Gioconda smile on its face, its threat is only the threat that we project on ourselves, now in the depths of the night, as we toss and turn between sheets that scratch our limbs. Why should the close and intimate statuette of death be any different from the glasses, for instance, or the wallet, or even the keys lying beside it? Nevertheless, in the thick of the night our hand gropes only for it, to take hold of the slender neck and throttle it in the darkness, for in the light of day we might be stopped by the expression on the painted face and the frozen aesthetic movement of the delicate, shapely limbs, which deceive us into thinking that it possesses life and a soul. And then, in the darkness, we hear the sound of the fall, for the groping hand has missed its mark, and as we get out of bed and crouch down to grope for the broken pieces, a sudden but absolute pain jolts our chest and stuns our heart, to tell us that death has indeed come to us and not to the pieces of clay strewn over the floor.

  Now that Lazar’s “space flight” had begun, guided by the three agile, swarthy technicians in charge of the state-of-the-art cardiopulmonary bypass machine—which was connected to many large and small plastic tubes coiling over the operating table and sucking the blood out of the square steel frame of the retractor as it slowly opened the heart like a book, and then streaming it back again—Nakash could leave his post at Lazar’s head and go out of the room to pour himself a cup of strong coffee from his private thermos. Although I was ready for a cup of the excellent coffee his wife made for him every morning myself, I couldn’t tear myself away, even though Dr. Yarden’s supervision of the patient’s anesthesia was more than adequate, especially since the respirator was still. Lazar’s heart as well as his lungs were paralyzed, and the rate of cleansed and oxygenated blood being pumped into the body and the brain was being determined by the instructions of the surgeon, who kept throwing changing orders over his shoulder. The three technicians would repeat them after him, like a crew of gunners making sure that no fatal misunderstanding should occur. The blood in the tubes flowed freely, with no danger of clotting, thanks to a continuous drip of Heparin, which neutralized the natural clotting factors and ensured an unimpeded flow between the turning wheels. The head of the technical crew enjoyed explaining to me how he pampered the bloodstream entrusted to his charge, warming and cooling it as required, as if it were an independent, sentient being that had to be soothed by an alkaline solution to neutral
ize the strong acidity produced by the trauma of being suddenly removed from the warmth of the human body and placed into the movement of the alien machine. When Dr. Yarden saw that Nakash wasn’t coming back immediately, he took a pack of cigarettes out of his pocket and beckoned me to approach the silent anesthesia machine, which didn’t really need an anesthetist but only a pair of eyes to watch the controlled drip of fentanyl and curare, which maintained the relaxation of the muscles and the analgesia. Levine too left the room, and next to the operating table there were now only three doctors, Dr. Adler, Professor Hishin, and myself. I took two footstools and placed one on top of the other so I could raise myself above the net protecting Lazar’s head, to give myself a better vantage point from which to look down directly at the implanting of the bypasses. This was now being purposefully performed by Dr. Adler, with the assistance of Hishin, who played the double role of pupil to his friend, addressing various technical questions to him, and teacher to me, generously passing on tidbits of clinical diagnosis or anatomical observations to satisfy the inquisitive gleam in my eye and to ensure that my presence, the reason for which was still not clear to him, would at least seem justified.

  That night as I lay in bed, before burying my face in the pillow and trying to fall asleep, I reviewed the six hours of the operation in my mind’s eye—Lazar’s naked genitals, his exposed heart reposing within the walls of his open chest, the blood coursing through the dozens of crisscrossing tubes, the silent bronze wheels of the cardiopulmonary bypass machine—and everything that had happened there seemed to me more harmonious, calm, and sure than I could possibly have imagined. Including the rather dramatic moment when the blood was returned to the body and Lazar’s heart refused to return to its sinus rhythm, a refusal that led Professor Adler to pull two electrodes from the defibrillator, place them on either side of the recalcitrant heart, and give it a few short electric shocks to start it and return it to the right rhythm, which appeared on the screen of the big monitor. Hishin and Levine had been right, I thought, lying in the dark in my bed, to bring in the Jerusalem master, who had worked with awe-inspiring competence and quiet confidence, and who had also dismissed with a reassuring gesture the fears I had dared to express when the operation was over. Although he was so tired after standing on his feet for six hours that he asked the nurse to help him divest himself of all the stuff encumbering him—the mask, the gloves, the headlamp, the sterile cap and gown—he seemed interested and willing to listen, with the patience of a wise physician who is never bored by anything to do with the human body. But Levine, who was still hostile toward me, broke in rudely to point out a mistake in one of the assumptions I had made, and Professor Adler, who had no desire to get involved in an argument, cut the discussion short, murmuring something reassuring about Lazar’s heart, and went out with Hishin to inform Lazar’s wife and the other members of the family of the success of the operation.