CHAPTER 41.

One Knot at a Time

ONE AFTERNOON, in my ninth month at Our Lady of Perpetual Succour, as we were on our way to the operating room, a bailiff served Deepak Jesuda.s.s with papers. My Chief Resident took them without comment, and we went on with our work. Well after midnight, as we sat in the locker room outside the theater and smoked, he smiled at me and said, "Anyone else would have asked me what the papers were about."

"You'll tell me if it concerns me," I said.

Deepak was perhaps thirty-seven when I met him. He had a youthful face and boyish shoulders that belied the bags under his eyes and the gray streaks in his hair. Had you seen us all in the cafeteria, you would have guessed B. C. Gandhi was the Chief Resident, because B.C. looked the part. But when I reflect back on my surgical training, I'm indebted to a small, dark man, a self-effacing surgeon whom the world might never celebrate. In the operating room, Deepak was patient, forceful, brilliant, creative, painstaking, and decisive-a true artisan.

"Don't stutter with that needle holder." "Self-discipline with those hands, Marion. Do each step just once, no wasted motion." When I learned to cross my hands the way he suggested to get equal tension on both limbs of the knot, a new problem arose: "Keep your elbows in, unless you're trying to fly." I redid more knots than I tied when I was with him. I took down entire suture lines and started again till he was satisfied. I gave new thought to light and exposure. "Working in the dark is for moles. We are surgeons." His advice was sometimes counter intuitive: "When you are driving, you look to see where you are going, but when you are making an incision, you look to see where you have been."

Deepak was from Mysore in southern India. That night in the locker room, he told me what I don't think he had told anyone else at Our Lady. When he graduated from medical school, his parents hastily arranged a marriage to a British-born Indian girl living in Birmingham; shed been a reluctant bride, bullied into marriage by her parents who didn't like the crowd she was hanging around with. She flew down with her family a few days before the wedding and left the day after, because she was attending college. It took six months for Deepak to get his visa and join her at her parents' home. He found that if he opened his mouth he embarra.s.sed her. She didn't want him near her in public or private. He left the house after a few weeks and found a house-officer position (equivalent to the internship in America) in Scotland. After a year he advanced to registrar, then to senior registrar. He pa.s.sed the difficult exams to become a Fellow of the Royal College of Surgeons, the magic letters FRCS behind his name.

"I could have gone back to Mysore. With my FRCS up on a board, I would have done very well. But I pictured all the people who'd come to my wedding. I didn't want to face them ... I just couldn't."

The next step for him in England would have been to be a surgical consultant appointed to a hospital. "There aren't many consultant jobs. Someone has to die for an opening to come up." After six years of working as a senior registrar, a consultant's understudy, doing all the emergency cases, Deepak decided to come to America.

"It meant starting all over again, because here you don't get credit for postgraduate training anywhere else. At my age, and after all the years of training, I wondered if I had it in me."

The American system of surgical training was different: after a year of internship and then four years as a surgical resident with ever increasing responsibilities (the last year as Chief Resident), one was allowed to sit for the exam to become a board-certified surgeon, a consultant.

"I did my internship in a prestigious place in Philadelphia. I worked hard for them ..." He closed his eyes and shook his head at the memory. "When my father died, I didn't even tell them. I didn't even try to take one day off for that. I was promoted to second year, even though I was performing at a much higher level, and they actually used me almost like a Chief Resident. But they b.u.mped me after the third year. One of my attending physicians who went to bat for me wound up resigning over this. He was so incensed.

"I could have gone into urology or plastic. That's what people often do if they're b.u.mped at that stage. Many foreign graduates give up and wind up in psychiatry or something. But I love general surgery The same guy who went to bat for me got me into another hospital, this time in Chicago, with the promise that I'd be promoted if I repeated my third year. I worked even harder-and got b.u.mped again." He laughed at my expression of incredulity. "It helps to be me, I suppose. To not expect too much. To love surgery for its own sake. But I was lucky. One of the attending physicians in Chicago went out on a limb for me. He called Popsy, and he arranged for me to come here as a fourth-year resident. That's the funny thing about America-the blessed thing. As many people as there are to hold you back, there are angels whose humanity makes up for all the others. I've had my share of angels. Popsy was one of those."

Popsy made Deepak Chief Resident overnight, but with the proviso that he be Chief Resident for two years. Deepak was in his last year of training when I arrived.

"So you will be done the same day I finish my internship?"

His silence made me anxious.

Slowly he shook his head.

"We got notice today of a site visit soon from the people who accredit our residency training program. If they don't like what they see, they can shut us down. We've got too few interns. And too few resident physicians at every level for the patient volume we handle. Not to mention too few faculty."

"How did this happen?"

"Our compet.i.tion is sweetening the pot. We were lucky to get you and Nestor and Rahul. We need more interns, more full-time faculty. Popsy just isn't as influential as he once was to attract good faculty. At this point, it's only Popsy s credentials and academic history that give our program accreditation. On paper, Popsy is golden. If Popsy steps down, or word gets out that he has early dementia, the house of cards falls."

I must have looked concerned because he said, "Don't worry. You'll be able to find another slot and get credit for this year."

"Is that what it is about-the bailiff serving you papers?"

"Oh, that's my so-called wife. Now she thinks I must be making a lot of money so she is filing in New York for spousal support. I have a lawyer who tells me that I have nothing to worry about. I owe her nothing."

"What about you, Deepak? What will you do if this place closes?"

"I don't know, Marion. I can't go through this again. Can't keep a.s.sisting someone who is my 'senior' but is butchering the case and doesn't have the sense to ask me to help. Maybe I'll just keep on working here. Sister Magda says the hospital will employ me. I'll live here, just like Popsy lives here. I'll operate. The hospital doesn't care if I am board certified or not, particularly if the residency program closes. Our Lady needs a surgeon. I'll be another Popsy. Believe it or not, Popsy, till his breakdown, was a super surgeon," Deepak said. "What's more important, he was a fine man. Truly color-blind."

After Mr. Walters's surgery, Deepak had spread the word that Popsy was not to operate anymore at any cost.

"Is there anything we can do to keep them from shutting us down?" I asked Deepak.

"Pray," he said.

CHAPTER 42.

Bloodlines

IPRAYED, BUT IT DIDN'T HELP. With two months to go to finish my internship and for Deepak to finish his Chief Residency, our program was placed on probation. I worried about my fate. It was bad enough that we might be closed down, but it would be worse not to get credit for the year I'd put in. I felt terrible for Deepak, who had come so close to finishing his Chief Resident year. Until our appeal was heard, though, and the final order came to shut us down, there was little to do but plod on.

On a Friday evening, I was summoned to the trauma room, and I reached there just as the ambulance roared in. The crew slid out a stretcher, snapped its wheels down, then raced in with it as if it were a battering ram. The gla.s.s doors parted just in time. I thought of these things as minor miracles, everyday efficiencies that were such a contrast to what I'd known in Africa. I jogged alongside. After almost a year at Our Lady, I'd done this many times, but the adrenaline still surged.

"John Doe, MVA, barely breathing at the scene," one of the men pushing the stretcher said. "Ran a red light, got broadsided by a van on driver's side. No seatbelt-went airborne through windshield ... Then, if you can believe this, his own car, spinning around, slammed into his body. Fly ball to centerfield ... Kid you not. Eyewitnesses. He landed on the pavement. No obvious neck injuries. Left ankle shattered ... bruises on chest and belly." I saw a handsome black male, clean-cut and no older than twenty.

The ambulance crew had two bags of intravenous saline going wide open. They had drawn blood, and now they handed over the red-, blue-, and lavender-topped tubes to the lab technician, who would begin typing and cross matching for blood before we'd even cut off the patient's clothes.

"There's more to this," the ambulance driver said. "Reason he ran the red light is because he was in a gunfight with g.a.n.g.b.a.n.gers. One of them got shot in the head. An ambulance is on its way with that guy. Don't worry ... it ain't no emergency. They had to scoop parts of his brain off the sidewalk-kindergarten through fifth grade from the looks of it. This guy," he said, pointing to our patient, "did the shooting."

Our patient's skull was intact, but he was unconscious. The part buzzed into his short hair was as straight as if it had been applied with a ruler. It was one of the strange things one noticed at such times. His pupils constricted briskly to the light I shone at them, a crude but rea.s.suring sign that his brain was all right. His pulse was thready and racing under my fingers. The monitor read one hundred sixty beats a minute.

A nurse called out the pressure. "Eighty over nothing." A few seconds later she said, "Fifty over zero."

Fluids were pouring in, blood was on its way. There was a bruise over the lower right ribs. His belly was tense and it seemed to be swelling under my eyes.

"No pressure," the nurse announced just as the X-ray technician arrived with the portable machine.

"No time for this. He's exsanguinating," I said. "Let's take him to the operating room. It's his only chance."

n.o.body moved.

"Now!" I said, giving the stretcher a push. "Call my backup, let them know."

In the operating room, I scrubbed for just thirty seconds, while Dr. Ronaldo, the anesthetist, adjusted the tracheal tube. Ronaldo looked at me and shook his head.

I pulled on my gloves while looking at what the scrub nurse had laid out.

"Forget sponges. Let's get lap packs. Open them out. We won't have time to unfold them. There is going to be so much blood. We'll need big basins to hold the clots."

The patient's belly was more tense than it had been downstairs.

Ronaldo, peering crocodilelike above his mask, shrugged when I looked at him for the signal to start.

"Get ready," I said to Ronaldo, " 'cause when I open, the pressure is going to bottom out."

"What pressure?" Ronaldo said. "No pressure."

For now, the blood expanding the belly was serving as a compress, tamping off the bleeding vessel wherever it was. But the moment I opened the belly, the geyser would open again. I layered pads all around. I poured Betadine over the skin, swabbed it off, said a prayer, and cut.

Blood welled out, spilled over the edge of the wound like a storm surge. Despite all the pads, despite my suction hose sucking greedily, the blood lapped over the drapes, onto the table, and splashed to the floor. I felt it soak through my gown, felt it on my thighs, in my socks, my feet squishing in my shoes.

"More packs!" Id tried to warn the nurses, but we were still unprepared for the torrent.

I reached in with my hand, displacing a second wave of blood as I grabbed the small bowel. With two hands now, I pulled loops out, fed them onto a towel by the side of the incision. In seconds I had effectively disemboweled the patient.

Deepak appeared across from me, scrubbed and ready. I clasped my hands together, stepped back to cross to the other side of the table, but he shook his head.

"Stay there," he said. He grabbed a retractor and pulled so I could see under the diaphragm.

I stuffed the lap packs all around the liver. Then I did the same on the left side, in the vicinity of the spleen. With cupped fingers, I scooped out the big clots that remained in the abdominal cavity. I jammed more packs all over the abdomen and into the pelvis, until everything was wedged tight. No blood vessel was pumping that I could see.

We could stop and take a breath.

"Are we catching up on blood?" I asked Ronaldo.

"We never catch up," he said. When I kept staring at him, he shrugged; he nodded at his dials as if to say things were no worse than when we began-that's what I hoped he had said.

Now I carefully removed the packs, starting with the spots where the bleeder was least likely to be. The pelvis was clean-no gusher there. Off came the pack around the spleen. If the patient's belly was a room, the furniture-the most movable, central structures-had been pulled out so we had a good view to the rear. If there was a bleed from a torn aorta or its branches, then this back wall of the abdomen-the retroperitoneum-would have shown a big ugly swelling, a hematoma. But that was clean, too.

I had a premonition that we would find the bleeder behind the liver. A place full of shadows, hard to see or fix. This was where the inferior vena cava, the largest vein in the body, carried blood back from the lower limbs and trunk, running through and behind the liver on its way to the heart. While coursing through the liver, it picked up the stumpy, taut hepatic veins that drained that organ.

I took the pack away from the liver. Nothing.

I gently pulled the liver forward, to look at its dark side.

An angry gush of blood filled the empty bowl of the abdomen. I hastily pushed the liver back, and the pumping ceased. Things were all right as long as we didn't touch the liver. What was it that Solomon, operating in the bush, had called this? The injury in which the surgeon sees G.o.d.

"Okay," Deepak said, "let's leave it like that."

"What now?"

"He's oozing from the skin incision and from all the IV sites. His blood isn't clotting." Deepak had a soft voice, and I had to lean over to hear him. "It's inevitable with this much trauma. We open them up, pour fluids into them, and the body temperature drops ... We have diluted the clotting system so it stops working. Let's pack around the liver and get out. Put him in ICU where we can warm him up, give him more fresh frozen plasma and blood. In a couple of hours, if he's alive, if he is more stable, we can come back."

I sandbagged the liver and fed the small bowel back into the wound. Instead of suturing the skin, we used towel clips to hold the wound edges together.

"The transplant teams will be here to harvest the corneas, heart, lungs, liver, and kidneys from the man he shot," Deepak said. "This theater is bigger, and I'll let them have it."

IN THE INTENSIVE CARE UNIT, two hours later, the oozing from the puncture wounds ceased. The cl.u.s.ter of poles and machinery around the bed made it tricky to get near Shane Johnson Jr.-that was his name. His family was in the waiting room, trying to fathom the unfathomable. Fresh frozen plasma, warmed blood, and fluids had given Junior a recordable blood pressure and a respectable temperature. He was alive, but just barely.

"Okay," Deepak said after rea.s.sessing the patient, and looking at the clock. "Let's go take another look."

This time we were in the smaller operating room. Ronaldo was still all gloom. Junior's face and limbs were puffy, his capillaries leaking out what was being poured into him. But we still had to pour fluid in to keep a blood pressure-it was like keeping a bucket full despite the holes in its side.

Deepak insisted that I be on the patient's right again. It took just seconds to remove the drapes, swab his skin, and pop open the towel clips that held the skin edges together. I removed the packs.

Deepak guided my fingers to the stalk of vessels that led into the liver. "Okay," he said. "Squeeze there." This was the Pringle maneuver. I squeezed, choking off the blood supply to the liver, while Deepak removed the last pad and lifted the liver forward. Blood gushed out at once, turning the dry clean field into a sopping red mess.

"Okay, you can let go," he said, pushing the liver back. "That's what I was afraid of. The vena cava is torn for sure. That's why, even with the Pringle maneuver, it still bleeds."

In some people, the inferior vena cava barely indents the back of the liver. In our patient, the vena cava was swathed by liver like a pig in a blanket. When Junior went airborne, then hit the pavement, his liver kept traveling; its momentum tore the short veins that anch.o.r.ed it to the vena cava, leaving a jagged rent.

Deepak asked for a suture on a long needle holder. At his signal I pulled the liver forward, and he tried to put the needle in one end of the tear. But before he could even see it, the field was awash with blood.

"G.o.d," I said, violating a cardinal rule about keeping quiet when a.s.sisting, "how do we fix this?"

Deepak said, "Oh, it's easy to repair the cava-it's just that the liver is in the way." It took me a second to realize this was as close as Deepak came to joking during surgery.

He was silent for a good while, almost in a trance, and I tried not to make a sound. At last, like a priest finishing a prayer, he moved. "Okay," he said. "It's a long shot. Let's switch sides."

I was unprepared for what followed. All I could do was marvel and be the best second pair of hands that I could be. Deepak swabbed Junior's chest, then cut vertically down over the breastbone from top to bottom, then ran an electric saw in the same groove. The smell of burning flesh and bone hung in the air. Suddenly the chest popped open like an overstuffed suitcase.

I didn't ask what he was doing. He didn't explain. My exposure to chest surgery had consisted mostly of draining fluid collections outside the lung or, rarely, watching Deepak resect a cancerous lobe. Three times during my internship we had cracked the chest and oversewn a stab injury to the heart. One of the three survived. This was one of the deficits in our program, one of the reasons we were being shut down: we had to ship off much of the thoracic surgery, not to mention much of the urology and plastic surgery, to other hospitals.

Junior's heart, a fleshy, yellow-streaked ma.s.s covered by the pericar-dial sac, was exposed, pumping away, as it had done for all his nineteen years. It had never been more threatened. Deepak cut open the pericardium.

I was aware of activity in the operating room behind me and in the scrub area that was shared. At one point, I looked around, and through the three sets of windows, I saw a crowd of white faces around the other operating table.

Deepak put a purse-string suture around the right atrium, the upper chamber of the heart that received blood from the vena cava. He took a chest tube and cut side holes in it with scissors. Now he made a nick in the atrium of the heart, in the center of his purse-string suture. Then he slid his newly fashioned tube into the atrium, using the purse string to cinch the tissue around the tube which he pushed down through the orifice of the inferior vena cava, and down to where our problem was.

"Tell me when it reaches the level of the renal veins," he said.

I saw the inferior vena cava distend, like a garden hose filling with water. "Now," I said.

"The tube serves as a stent for the inferior vena cava," Deepak said, leaning over to look from below. "It's also a crude bypa.s.s so blood from the trunk can return to the heart while we make the repair. Now ... let's see if we can fix this."