In the OR, Royer's team had transformed the county hospital into a state-of-the-art operating theater. Calm-and-collected had replaced the chaos. Seasoned professionals now tended Annie's monitors. Sal sat in the hall, holding his unlit pipe and smiling as if he had been responsible for the transformation.
The room was stage-bright, totally sterile, and nondescript, not a picture anywhere, stainless steel tables, draped in pale bluegreen, an assortment of odd-looking instruments laid out in some order across what looked like a sterile tablecloth. One whole wall was covered in gauges, machines, and sterile battleship gray. All the machines gave varying but equally important readings on anesthesia, the volumetric infusion pump, the ventilator, and different lines leading from tanks somewhere out of the room that piped in helium, oxygen, and nitrous oxide.
When the anesthesiologist had put Annie into a deep sleep with an intravenous medication, and while I put Annie on pump, the on-call surgeon poked a catheter into the artery in her left wrist-a small arterial line that allowed us to monitor blood pres sure moment by moment. This finished, he stuck another catheter into a vein in her chest-to give her medicines and measure intravascular volume.
A scrub nurse ran a small tube catheter into her bladder so we could follow her urine output. Normally we would shave a patient's body hair, but Annie didn't have any, so they simply swabbed her down with soap and water.
In my past life, I would have sat back and watched, honoring the line drawn between doctors and nurses. But for the first time since my internship, I stepped up to the chief resident and honored my relationship with the patient above all else. I said, "You mind?"
A bit surprised, he shook his head and stepped aside, allowing me to set the pace and tone. As we sponged her with Betadine, I noticed how thin her arms had grown, how drawn and skinny her hips. Like Emma's those last few days at the lake, Annie's skin had become almost translucent.
People used to ask me, amid so much terror, pain, and hardship, how transplant surgeons could stay so hopeful. So positive. Whenever asked that, I remembered the look behind Emma's eyes and asked how could we not.
We covered Annie's chest with the surgical equivalent of Saran Wrap and then gently draped her with two sterile sheets, leaving a small strip of exposed chest and upper abdomen. In medical school, we learned to call that the surgical field, where we'd focus all our energies. Ordinarily, it helped distance us from the person attached to it.
Maybe that's why I stepped up and swabbed Annie. I didn't want that distance.
I stepped to the foot of the bed, felt Annie's cold toes, and turned to a nurse. "Think you could find some socks?"
She smiled and disappeared.
As a result of her previous open-heart surgery, Annie's chest cavity possessed a lot of dense scar tissue, or adhesions, between the back side of her breastbone and her heart. I knew when Royer arrived I'd have to further divide the scar carefully, making sure not to injure or rupture the cavity any more than I already had.
Most of the hearts I had removed were two or three times the size of normal ones, suffering from dilated cardiomyopathy. That meant they were big, flabby, swollen sacs that didn't beat too well. Annie's was no different. I hoped that the heart Royer found would fit in the space we had, because I didn't want to have to trim it. And hearts are fickle, they don't let you trim them much. I also hoped that he would hurry, because thousands and thousands of its cells were dying every minute it was out of the body. Every second it failed to pump, the farther we traveled from getting it going again.
The moment Annie went on bypass, the tubes shunted her blood away from her heart and ran it into what looked like a cross between the back of a pipe organ and something out of Frankenstein's laboratory. On one side of the cardiopulmonary bypass machine was a row of glass canisters that some have compared to high-tech versions of ice-cream makers. As Annie's blood fed into the canisters, the machine gave it oxygen and then pumped the enriched blood out again, back into Annie's ascending aorta.
On the other side of the bypass machine, the perfusionist closely watched a series of calibrated gauges; just a few feet away, the anesthesiologist tracked a series of gauges, looking at pressure and how much oxygen she took in and how much carbon dioxide she expelled. When we got her going again, there were two things I didn't want to hear from him: "Pressure's getting low" or "Flow's fallen off." In order not to hear that, I needed him on his toes. At the same time, I didn't need him mad at me. That wouldn't help Annie. I caught him in the hall and pulled him aside. "Can I ask you a favor?"
Expecting a barked order, the question caught him off guard. He looked at me through his glasses and shrugged. "Sure."
"In her last surgery, she woke up."
He gulped, shook his head in disgust, and then nodded. I didn't have to continue.
"Don't worry. I've got some sweet dreams planned for that girl."
Anticipating a long day and the fact that, normally, doctors hand off their patients sometime around midmorning, I asked him, "When are you scheduled to sign out?"
He shook his head. "My partner arrived an hour ago. She's handling the other seven in my care." He looked at Annie. "But ... not her. I'm here as long as you need me."
I put a hand on his shoulder. "Thanks."
I walked down the hall and past the one-way window that gave medical staff a view of the waiting room. Charlie, bloody but unharmed, sat listening to and smelling the world around him while Cindy stood at a nearby window, staring five thousand miles beyond the walls of the hospital and biting her nails to the quick. Termite leaned against a soda machine, looking at the choices but not really looking at the choices, unconsciously turning his Zippo over and over in his hand. And in the far corner, off by himself, eyes closed, forehead matted with sweat, lips moving, Davis knelt against a chair, his elbows leaning on a tattered Bible.
I closed the door of the doctors' lounge and looked out through the window that viewed a pasture and a dozen or so milk cows all vying for a chance to stand in the center of the creek. Their udders looked like taut balloons and their jaws worked in rhythm with one another. A light, gentle rain had begun to fall.
I leaned against the window, closed my eyes, and thought of Emma. The way she had told me to take a nap, the tired look behind her eyes, the assuring smile she'd given me as I carried its off to bed. And I thought of the sleep I couldn't hold off. I looked at my arms and ran my fingertips along the fading reminders of her panic. Last, I thought of the pain she must have known and felt for the half hour that I didn't wake up.
All my life, I'd had an almost photographic memory. But while I looked out that window, with Annie breathing through a machine just over my shoulder and Cindy tied in knots in the waiting room just around the corner and Royer speeding toward us, I could not, for the life of me, remember anything Shakespeare had ever written. Nor, for that matter, anything by Tennyson, Milton, or Coleridge. My companions were gone and had taken their comfort with them.
I reached for Annie's sandal around my neck. Beneath it hung Emma's medallion. Draped in memory, I had none of my own. My mind felt as if someone had walked to the chalkboard and wiped the slate clean. I rubbed the sandal, felt the worn letters, closed my eyes, and searched again. All I could see was Emma's face just before the medic placed his hand over her face and closed her eyes.
The intercom crackled above me. "Dr. Jonathan Mitchell, line one. Dr. Jonathan Mitchell, line one."
Royer.
I reached up for the phone-one last time. I could hear the helicopter in the background.
Jonny? Twelve minutes."
"We'll be waiting." I hung up and stood there. I knew that if my life had led to one moment, it was coming now.
I told the chief resident that Royer would be there in twelve minutes and then walked to the room where the others waited. Cindy saw my face, the puffy, tired look of passing pain, and she stood up, looking cold and reflecting me. Charlie heard her stand and did likewise.
"It's not long
now," I said quietly. "I'll keep you posted as best I can." Cindy tried to say something, but I shook my head and put my hand on Charlie's shoulder. "Keep her company, will you?"
Charlie looped his arm inside Cindy's and nodded. I walked back down the hall and through the double doors and hit the button above the sink. Nine minutes later, I walked into the OR, hands held high, and a nurse held my gloves while I sank my hands in deep. Then she helped wrap me in a sterile gown, tied my mask behind my head, and turned on my headlamp. I peeked below the sheet to make sure Annie's eyes were closed. The anesthesiologist sat behind the sheet monitoring six machines and noting numbers on a clipboard.
The helicopter set down outside and an alarm sounded, accompanied by a series of flashing red lights running up and down the halls. Royer walked in the door carrying a red-andwhite cooler, with the calm and collectedness of a man delivering a pizza.
"Sorry to keep you waiting," he said. "Traffic on the perimeter was a bear, and ..." He shrugged. "We lost the directions." He stepped to the sink and punched the button on the timer. Eight minutes later the timer sounded. He rinsed, sank his hands into 7-1/4 gloves, stepped into the waiting sterile green gown, and asked the nurse to adjust his mask and the angle of his lamp. Then he looked at me. "Your move, Doctor."
Around us, the team had assembled: a resident ready at my left, the perfusionist behind Royer, a scrub nurse at the table next to him, several more waiting at the foot of the bed, the anesthesiologist at Annie's head. All eyes were on me.
I had never sought the attention garnered by transplant surgeons. That wasn't why I took this job. But one thing about it, like a quarterback, you had it whether you wanted it or not. If you fumbled, everyone knew it, and if you scored, everyone knew that too.
I held out my hand and whispered, "Scalpel ... please."
In a few moments I was reaching in and sinking my hand beneath Annie's still heart. I made six precise cuts, careful not to disturb the lines running into her, then pulled and lifted out the heart.
Royer held out a metal pan, looked at me above his mask, and whispered, "There's a lot of love in that one."
Just before I dropped it into the pan, he noticed the purse stitch I had made amid the rubble on the floor of what used to be my workshop. He ran his fingers across the lines and looked at me. "That how you got her here?"
I nodded.
"And she made it to this table still pumping?"
I nodded again.
He turned to the nurse next to him. "Make sure we keep that." He looked at me. "A lot of folks in our profession have doubted that could ever be done. This might make a few believers. Cardiac pathologists for years to come will study that stitch and, who knows? It might just save a few lives."
Even dead, Annie's old heart was about to begin a new journey, which, when ended would open doors for other Annies.
I laid it gently in the pan while Royer reached into the cooler, dipped his hands below the ice level, and pulled out the grayishpink donor heart, carefully passing it to me. Feeling for any sign of disease, I ran my fingers along the arteries. I felt the muscles, the valves, and dimensions of the heart in relation to one another. It was larger than normal, but its tone told me that it was large due to exercise, not disease. Somebody had worked this heart, and as a result, it would fit. In fact, it was near perfect.
Royer spoke up. "What your fingers won't tell you is that she was a high-school kid. A cross-country runner. Parents say she was pretty good too."
He was suctioning excess blood from Annie's chest cavity and placing the first stitch while I lowered the new heart into Annie's chest. Hearts are slippery, so you never want to hold too tightly. But also not too loosely. It's sort of like holding a puppy. You need a good firm hold, but there's a limit.
I held the symbol of life in my hands and marveled just as much then as I had the first time in my anatomy class. This is it. The wellspring.
Royer placed a hand on mine, and eyes smiled at me above his mask. "Remember, right side up."
A heart transplant is a rather straightforward operation, comprising four anastomoses-a derivation of a Greek word meaning "to join mouth to mouth." First we connected the donor heart's left atrial chamber to what remained of Annie's left atrium, creating an entirely new chamber. Next we sewed the two right atrial chambers together. Then we took the donor's aorta and attached it to Annie's, end to end. Finally, we attached the pulmonary arteries.
I sewed while Royer positioned the heart and kept tension on the suture material to assure good apposition of the tissues. Despite the way he bragged about my abilities as a surgeon, transplantation was very much a team act.
Royer poured a bucket of ice-cold saline on the heart as I continued sewing, in order to keep it as cold as possible during its exposure to the hot operating room lights. He looked at the clock on the wall. "We're in good shape. Lots of time. It's 10:07."
"Ischemic?" I asked.
"Still have almost an hour."
Stitching in the heart took about an hour minus a few minutes. All the while, the circulating nurse made trips to pick up more blood products or drop off a blood gas sample for the lab. When she returned, her arms full of clear plastic bags of plasma, she was met by the anesthesiologist, who checked the receipt of each one.
When we needed blood, the anesthesiologist would hook up a packet to one of the tubes running into Annie's body and suspend it high in the air on a pole. While Annie was on bypass, the accordion-like pump of the ventilator would remain still and deflated because the heart-lung machine did the breathing for her.
Royer checked the lines and said without looking at me, "Heard you gave blood today."
It was a leading statement. I nodded without looking up.
The sutures required in transplantation are large and take big bites into the tissue, taking into account the full thickness of the heart's wall and its surrounding fat. In contrast to the almost minute stitches needed in a routine bypass operation, where magnifying glasses were helpful, these seemed gigantic.
Royer poured another bucket of cold saline, and I took more large bites to prevent further bleeding. He pulled on the lines to make sure the sutures were tight enough to withstand the changing pressures of a beating heart over one hundred thousand times a day for the next four or five decades. Ever the teacher, he turned to the resident to my left. "Big bites like these guarantee a secure anastomosis and allow us to achieve hemostasis."
The resident nodded.
I finished the left atrium, then made an incision in the right. I reminded myself that it's important to make the incision away from the sinus node, the region of the heart that produced all its electrical activity. If every heart has its own beat, and it does, then it's the sinus node that is the drum.
I finished the anastomosis of the right atrium, leaving only the final connections of the two aortas and pulmonary arteries. That meant we were about an hour away from coming off bypass. I turned to a nurse.
"Would you please tell Cindy everything's going fine?" I checked the numbers on the machines all about me. "Annie's doing well. I'll be out in a bit."
She nodded and disappeared.
I trimmed the aorta of the donor heart. Of Annie's new heart. If God had given me a gift, part of it occurred here. In these incisions. It was vital, both now and in the decades to come, that this fit be perfect. Textbooks couldn't teach it. It was like sculpting; the doctor either could or could not fit the two together.
When I placed the arteries against Annie's own, Royer smiled and shook his head. I sewed the two aortas together and turned to the perfusionist.
"Let's warm her up."
I did this not to restart the heart, but to check my stitching and determine if I had any leaks-a trial run.
During the operation we had cooled the blood in the heartlung machine by about twenty degrees, to slow Annie's metabolism. This would decrease the body's demand for oxygen, and preserve the vitality of the heart muscle cells. Once I stitched together the aor
tas, we reheated the oxygenated blood, and as it flowed through the machine and into the coronary arteries that fed the heart, the heart slowly warmed up. As it did, its color changed-from dead gray to alive red. I wrapped my fingers gently around its growing volume, felt the chambers grow taut, and felt life fill the emptiness.
I placed the final sutures in the pulmonary artery, and the rich, warm blood began pouring into the new heart, feeding its millions of cells that had been starving for three hours and fortyeight minutes. I tugged gently on the heart and noticed one anastomosis that did not hold the way I thought it should. I turned to the perfusionist and said, "Hold her off and give me about five minutes."
I made the adjustments, turned once again to the perfusionist, and nodded. Again the heart filled and began to quiver like a steaming kettle just before it boiled. I held my breath.
I reached for the defibrillator paddles behind me, often used to start up a transplanted heart or shock it into a sinus rhythma regular pattern. I massaged the heart once, using my hand to remind it that it once had a rhythm. Hearts forget, but up to a point, they can be reminded.
It beat once, a hard jolting, pounding beat. It torqued, pumped itself empty, and refilled. The screaming flatline above me beeped once. Around the table, we waited for the second and the third and the ...
It didn't come.
Royer's face wrinkled with concern. I reached for the paddles and said calmly, "Charge to 100."
The nurse waited for the light to turn green and nodded at me. I slid the paddles alongside Annie's heart and said, "Clear." The heart jerked, almost shaking itself free of the current that swam through it, and then lay still.
I said it again. "Charge to 200."
Royer's face studied mine while I studied Annie's heart. It jumped again, and fell quiet, limp, and unresponsive. I paused, thought back through the process. Everything had been perfect. Why won't it start?
I shook my head and whispered, knowing it would be the last time. "Charge to 300."
The light turned green, and I shocked Annie's heart to where it rocked and spasmed, tugging violently against the sutures that held it. I pulled out the paddles and waited, but Annie's heart didn't even twitch. I reached in with my hand, wrapped it around the heart and massaged, pumping for her. Trying to pass life from my hand to her heart. I felt it fill and empty with each successive squeeze. And each time, it fell limp and melted into my aching palm. I squeezed for several minutes until my hand began to cramp. After ten minutes, it locked up.
When Crickets Cry Page 29
