Strangers

Page 9

Ginger's entire life had been a funnel, focusing on this moment: for the first time, she was assuming the senior surgeon's role in a major and complicated procedure . Years of arduous education, an immeasurable weight of hopes and dreams, lay behind her ascension to this moment. She had a prideful yet humbling sense of just how great a distance her journey had covered.
And she was half sick with dread.
Mrs. Fletcher had been anesthetized and draped in cool green sheets. None of the patient's body was visible except that portion of her torso on which surgery would be performed, a neat square of flesh painted with iodine and framed by limecolored cloth. Even her face was out of sight beneath tented sheeting, as an added precaution against airborne contamination of the wound that would shortly be made in her abdomen. The effect was to depersonalize the patient, and perhaps that was in
part the intent of the draping, as well, thereby sparing...
need to look upon the human face of agony and death if, God forbid,-his skill and education should fail him.
On Ginger's right, Agatha Tandy, the surgical technician, stood ready with spreaders, rakes, hemostats, scalpels, and other instruments. On her left, a scrub nurse was prepared to assist. Another scrub nurse, the circulating nurse, the anesthesiologist, and his nurse also waited for the procedure to begin.
George Hannaby stood on the other side of the table, looking less like a doctor than like the former star fullback on a pro football team. His wife, Rita, had once talked him into playing Paul Bunyan in a comedy sketch for a hospital charity show, and he had appeared at home in woodsman's boots, jeans, and a red plaid shirt. He brought with him an aura of strength, calmness, and competency that was most reassuring.
Ginger held out her right hand.
Agatha put a scalpel in it.
A keen, thin, bright curve of light outlined the razorsharp edge of the instrument.
Hand poised over the score lines on the patient's torso, Ginger hesitated and took a deep breath.
George's stereo tape deck stood on a small table in the corner, and familiar strains of Bach issued from the speakers.
She was remembering the ophthalmoscope, the shiny black gloves. . . .
However, as frightening as those incidents had been, they had not utterly destroyed her selfconfidence. She had felt fine ever since the most recent attack: strong, alert, energetic. If she had noticed the slightest weariness or fuzzymindedness, she would have canceled this procedure. On the other hand, she had not acquired her education, had not worked seven days a week all these years, only to throw away her future because of two aberrant moments of stressrelated hysteria. Everything was going to be fine, just fine.
The wall clock said sevenfortytwo. Time to get on with it.
She made thefirst cut. With hemostats and clamps and a faultless skill that always surprised her, she moved deeper, constructing a shaft through skin, fat, and muscle, into the center of the patient's belly. Soon the incision was large enough to accommodate both her hands and those of her assisting physician, George Hannaby, if his help should be required. The scrub nurses moved close to the table, one on each side, grasped the sculpted handles of the retractors, and pulled back gently on them, drawing apart the walls of the wound.
Agatha Tandy picked up a fluffy, absorbent cloth and quickly blotted Ginger's forehead, careful to avoid the jeweler's lenses that protruded from her operating glasses.
Above his mask, George's eyes squinted in a smile. He was not sweating. He seldom did.
Ginger swiftly tied off bleeders and removed clamps, and Agatha ordered new supplies from the circulating nurse.
In the brief blank spaces between Bach's concertos and in the silence at the end of the tape before it was turned over, the loudest sounds in the tilewalled room were the sibilant exhalations and groaning inhalations of the artificial lung machine that breathed for Viola Fletcher. The patient could not breathe for herself because she was paralyzed by a curarederived muscle relaxant. Though entirely mechanical, those sounds possessed a haunting quality that made it impossible for Ginger to overcome her apprehension.
On other days, when George cut, there was more talk. He traded quips with the nurses and the assisting resident, using light banter to reduce the tension without also reducing concentration on the vital task at hand. Ginger was simply not up to that sort of dazzling performance, which seemed akin to playing basketball, chewing gum, and solving difficult mathematical problems at the same time.
Having completed the excursion into the belly, she ran the colon with both hands and determined that it was healthy. With damp gauze pads provided by Agatha, Ginger cradled the intestines, placed the hoelike blades of the retractors against them, and turned them over to the scrub nurses, who held them out of the way, thus exposing the aorta, the main trunkline of the body's arterial system.
From the chest, the aorta entered the belly through the diaphragm, running parallel to the spine. Immediately above the groin, it split into two iliac arteries leading to the femoral arteries in the legs.
“There it is,” Ginger said. “An aneurysm. Just like in the X rays.” As if to confirm it, she glanced at the patient's X ray that was fixed on the light screen,'on the wall at the foot of the operating table. "A dissecting aneurysm, just above the aortic saddle."
Agatha blotted Ginger's forehead.
The aneurysm, a weakness in the wall of the aorta, had permitted the artery to bulge outward on both sides, forming a dumbbellshaped extrusion full of blood, which beat like a second heart. This condition caused difficulty in swallowing, extreme shortness of breath, severe coughing, and chest pains; and if the bulging vessel burst, death followed swiftly.
As Ginger stared at the pulsing aneurysm, an almost religious sense of mystery overcame her, a profound awe, as if she had stepped out of the real world into a mystic sphere, where the very meaning of life was soon to be revealed to her. Her feeling of power, of transcendence, rose from the realization that she could do battle with deathand win. Death was lurking there in the body of her patient right now, in the form of the throbbing aneurysm, a dark bud waiting to flower, but she had the skill and training to banish it.
From a sterile package, Agatha Tandy had taken a section of artificial aortaa thick, ribbed tube that split into two smaller tubes, the iliac arteries. It was woven entirely of Dacrol. Ginger positioned it over the wound, trimmed it to fit with a pair of small sharp scissors, and returned it to the technician. Agatha put the white graft in a shallow stainlesssteel tray that already contained some of the patient's blood, and swished it back and forth to wet it thoroughly.
The graft would be allowed to soak until it had clotted a bit. Once it was installed in the patient, Ginger would run some blood through it, clamp it, allow that blood to clot a bit more, then flush it out before actually sewing it in place. The thin layer of clotted blood would help prevent seepage, and in time the steady flow of blood would form a neointima, a leakproof new lining virtually indistinguishable from that in a real artery. The amazing thing was that the Dacron vessel was not merely an adequate substitute for the damaged section of aorta but was, in fact, actually superior to what nature had provided; five hundred years from now, when nothing remained of Viola Fletcher but dust and timeworn bones, the Dacron graft would still be intact, still flexible and strong.
Agatha blotted Ginger's forehead.
“How do you feel?” George asked.
“Fine,” Ginger said.
“Tense?”
“Not really,” she lied.
He said, “It's a genuine pleasure watching you work, Doctor.”
“I'll second that,” said one of the scrub nurses.
“Me, too,” the other said.
“Thanks,” Ginger said, surprised and pleased.
George said, "You have a certain grace in surgery, a lightness of touch, a splendid sensitivity of hand and eye that is, I'm sorry to say, not at all common in the profession."
Ginger knew that he never gave voice to an insincere compliment, but coming from such a stern taskmaster, this bordered on excessive flattery. By God, George Hannaby was proud of her! That realization flooded her with warm emotion. If she had been anywhere but in an operating room, tears would have come to her eyes, but here she kept a tighter rein on her feelings. However, the intensity of her reaction to his words made her aware of how completely he had filled the role of fatherfigure in her life; she took nearly as much satisfaction from his praise as she would have taken if it had come from Jacob Weiss himself.
Ginger proceeded with the operation in better spirits. The disturbing possibility of a seizure slowly receded from her thoughts, and greater confidence allowed her to work with even more grace than before. Nothing could go wrong now.
She set about methodically controlling the flow of blood through the aorta, carefully exposing and temporarily clamping all branching vessels, using thin elastic loops of extremely pliable plastic tubing to valve off the smaller vessels, placing mosquito clamps and bulldog clamps on the larger arteries, including the iliacs and the aorta itself. In little less than an hour, she had stopped all blood flow through the aorta to the patient's legs, and the throbbing aneurysm had ceased its mocking imitation of the heart.
With a small scalpel, she punctured the aneurysm, releasing a pool of blood; the aorta deflated. She sliced it open along its anterior wall. At that moment, the patient was without an aorta, more helpless and more dependent upon the surgeon than at any other time. There was no going back now. From this point on, the operation must be conducted not only with the greatest care but with the most prudent speed.
A hush had fallen on the surgical team. What little conversation there had been now ceased. The Bach tape had reached the end again, and no one moved to turn it over. Time was measured by the wheezing and sucking of the artificial lung machine and by the beeping of the EKG.
Ginger removed the Dacron graft from the steel tray, where it had been soaking up blood and clotting precisely as desired.
She sewed the top of it into the aortal trunk, using an extremely fine thread. Then, with the top of the graft sewn in place and the unattached bottom clamped off, Ginger filled it with blood to let it clot again.
Throughout these steps of the operation, it had not been necessary for Ginger to have the sweat blotted from her forehead. She hoped that George noticed her new drynessshe was sure he did.
Without needing to be told that it was once again time for music, the circulating nurse reset the Bach tape.
Hours of work lay ahead of Ginger, but she pressed on without the least weariness. She moved down the draped body, folding back the green sheets,,revealing both of the patient's thighs. With the help of the circulating nurse, Agatha had replenished the instrument tray and was ready now with everything that Ginger needed to make two more incisions, one in each of the patient's legs, below the inguineal creases, where the legs attached to the body trunk. Clamping and tying off vessels, Ginger eventually exposed and separated the remoral arteries. As with the aorta before, she used thin elastic tubing and a variety of clamps to valve off the blood flow through these vascular fields, then opened both arteries where the bifurcated legs of the graft would attach to them. A couple of times she caught herself humming along happily with the music, and the ease with which she worked made it seem almost as if she had been a surgeon in an earlier life, now reincarnated into the elite brotherhood of the caduceus, predestined for this labor.
But she should have remembered her father and his aphorisms, the bits of wisdom that he had collected and with which he had gently lectured or patiently admonished her on those rare occasions when she had been less than well behaved Or when she had failed to do her very best in school. Time waits for no man; God helps those who help themselves; a penny saved is a penny earned; resentment hurts only those who harbor it,- judge not that ye be not judged.... He had a thousand of them, but there was none he liked better and none he repeated more often than this one: Pride goeth before a great fall.
She should have remembered those six words. The operation was going so well, and she was so happy with her work,
so proud of her performance in this first major solo flight, that she forgot about the inevitable great fall.
Returning to the opened abdomen, she unclamped the bottom of the Dacron graft, flushed it out, then tunneled the twin legs of it beneath the untouched flesh of the groin, beneath the inguineal creases, and into the incisions she had made in the femoral arteries. She stitched in both terminuses of the bifurcated graft, unclamped the restricted vascular network, and watched with delight as the pulse returned to the patched aorta. For twenty minutes, she searched for leaks and knitted them up with fine, strong thread. For another five minutes, she watched closely, in silence, as the graft throbbed like any normal, healthy arterial vessel, without any sign of chronic seepage.
At last she said, “Time to close up.”
“Beautifully done,” George said.
Ginger was glad she was wearing a surgical mask, for beneath it her face was stretched by a smile so broad that she must have looked like the proverbial grinning idiot.
She closed the incisions in the patient's legs. She took the intestines from the nurses, who were clearly exhausted and eager to relinquish the retractors. She replaced the guts in the body and gently ran them once again, searching for irregularities but finding none. The rest was easy: laying fat and muscle back in place, closing up, layer by layer, until the original incision was drawn shut with heavy black cord.
The anesthesiologist's nurse undraped Viola Fletcher's head.
The anesthesiologist untaped her eyes, turned off the anesthesia.
The circulating nurse cut Bach off in midpassage.
Ginger looked at Mrs. Fletcher's face, pale now but not unusually drawn. The mask of the respirator was still on her face, but she was getting only an oxygen mixture.
The nurses backed away and skinned off their rubber gloves.
Viola Fletcher's eyelids fluttered, and she groaned.
“Mrs. Fletcher?” the anesthesiologist said loudly.
The patient did not respond.
“Viola?” Ginger said. “Can you hear me, Viola?”
The woman's eyes did not open, but though she was more asleep than awake, her lips moved, and in a fuzzy voice she said, “Yes, Doctor.”
Ginger accepted congratulations from the team and left the room with George. As they stripped off their gloves, pulled off their masks, and removed their caps, she felt as if she were filled with helium, in danger of breaking loose of the bonds of gravity. But with each step toward the scrub sinks in the surgical hall, she became less buoyant. A tremendous exhaustion settled over her. Her neck and shoulders ached. Her back was sore. Her legs were stiff, and her feet were tired.
“My God,” she said, “I'm pooped!”