At the Scent of Water

by Linda Nichols

  There had been an emergency. A newborn had been transferred in with a complex defect, medicalese for a heart that bore little resemblance to a normal functioning pump, bore little resemblance, in fact, to any recognizable defect. This specific one had required emergency surgery, and he had been on call. He had pulled off Interstate 40 into a Citgo station to take the call, had listened, given a few instructions, then turned his car around and headed back to the hospital. He had thought about the case all the way back, forgetting even to call his mother and tell her he would not be coming home.

  The child had survived but was now hospitalized again, a year later. He would probably live his short life in and out of the ICU, undergoing an endless panoply of tests and procedures. Well, there was nothing he could do about that. That part was out of his control. He had done his part as well as a human could. No one else could have done it better, so he felt the pressure ease for a moment.

  He was the best. Around these parts, at any rate, or so they said. He supposed they were right, though he realized the fact with a heaviness the responsibility brought rather than with the pride he had felt at one time. The Cleveland Clinic had Roger Mee. Michigan had Ed Bove and Frank Hanley. Boston had Richard Jonas. And Good Samaritan Children’s Hospital of Knoxville had Sam Truelove.

  He thought about his actual skills and knew they did not explain his success. He could sew a fine line of stitches and do it quickly, and he had an ingenuity, an ability to visualize and manipulate objects in space. But neither of those abilities accounted for what he had been then. Before. He hadn’t had to plan or think. He had known almost instinctively how to fix the broken ones. It had been effortless action, filled with grace and energy.

  He could barely remember that now. He flipped on the CD player, and his uncles’ gospel quartet rang out. He listened to it as he drove, the strands of the melody and harmony interweaving. “I will arise and go back to my father’s house,” their voices declared. He could see their faces in his mind as they sang, confident, shining, and he wondered when he had stopped believing.

  That song ended. The next song began. “I’m in love with my Savior and He’s in love with me,” they sang out. He punched the switch and they were silent. He needed quiet. He needed to think. He flipped open his briefcase as he maneuvered through traffic, taking intermittent sips of coffee as he reviewed the charts for the surgeries he would perform today.

  The first would be a repair of a TGA—transposition of the great arteries. He had developed a new technique for repairing this defect in which the large vessels are reversed, the aorta carrying low-oxygen blood to the body and the pulmonary artery carrying oxygen-rich blood back to the lungs. His success rates made others think the risky procedure was almost routine for him. He rehearsed, imagining the tiny vessels, moving them around in his mind, the heart and environs three-dimensional in the space of his imagination.

  His second case would be performing part two of the three-step correction of a hypoplastic left heart. Years ago, or even today, at a less-skilled facility, this child would have died. She was born with the crucial pumping chamber of her heart nothing more than a malformed mass of nonfunctional muscle. He had done the first step himself, which had reduced the stress on the heart. Today’s procedure would make the heart a two-chambered pump. The third step would make it as functional as it could be. It was still a terrible defect, and it remained to be seen what the long range outlook for the child would be. But it wasn’t his job to know that, to even think about that. His job was to do the best he could for them now.

  The next procedure was to correct a tetralogy of Fallot. He would fix two of the syndrome’s defects: the hole between the chambers and the narrowing of the pulmonary artery. He felt an easing of pressure at the realization that he could do these things. He could. Still, he rehearsed, imagining what he would do, the steps he would take.

  He dreaded tomorrow’s schedule. The first case was another complex defect. The child’s heart was a bad joke, a grotesque collection of malformations. His few weeks of life had been torturous. He had been refused surgery by two other pediatric cardiac surgeons, so the parents had come to him. To the one who had the reputation for taking on anything. The one who was better than anyone else. His jaw tightened, and he felt a familiar bruising around his own heart.

  They were children. They hadn’t lived their lives yet, and he would not stand idly by and let them be robbed if there was something he could do. There would probably be little he could do for that child, but the parents had begged. Literally begged and he had promised to open him up and take a look.

  He felt the anger well up in him that a child, so fresh and vulnerable, was being hurt, and he knew, regardless of the oughts or shoulds of such a thing, who his anger was aimed at. He and the Almighty had been at war for many years now. Five, to be exact, and there was no enmity so bitter as that between those who had once been intimate friends.

  He set his jaw and tossed the last file aside. He could do them. He had done them before. He could do them again, though he knew the truth. What he did now was mechanical and rote compared to the way it used to be. He used to have almost a magic in his hands. No. That was wrong. He stared at the traffic and realized what it had been. A filling. An empowering. He had felt as if his hands were merely the instrument that the Almighty himself had used to repair those broken hearts. And he knew just as well that the Almighty had set him aside. His chest filled with a heavy bitterness. When God had left him, He had taken away the gift, as well.

  Well, he was still better than anyone else. With or without divine intervention. He set his jaw and his will, but underneath he could feel the weariness set in like a deep, cold misery that had latched on and would not let go. What had once been effortless and energizing now left him shaking with fatigue, carved out deep within him a relentless gnawing hunger for silence and peace and rest. He gave his head a small shake and took another drink of his coffee.

  His cell phone rang. He picked it up. “Truelove,” he said shortly.

  “Hey, bro.” It was Ricky, not the hospital, and Sam relaxed a hair.

  “What are you up to?” Sam asked his brother. His usual greeting, and for most of their lives a legitimate question. What scrape am I going to have to rescue you from? What have you done now? The last of those calls had been many years ago, though.

  They talked about nothing, but Sam knew why his brother had called. He was checking. Just checking. They were always checking and worrying about him these days. Even his mother, who did not believe in divorce and remarriage, had urged him to get out more, to make some friends. To do something besides work and sleep.

  He reassured his brother, ended the call, then brought out his voice-activated recorder and dictated a few letters. One to an insurance company, four to referring doctors whose patients he had seen. By the time he arrived at the hospital, it was only six o’clock in the morning. His surgery began at nine. He would be in surgery all day, well into the evening. He would not see the sun at all today, and once again he wondered why he bothered to leave the hospital at all. He parked his car in the physicians’ lot, rode the elevator up to the Pediatric ICU floor. The unit was on one side, his office on the other. He went in, and as usual, Isabella was there already.

  Isabella, his right hand, combination mother and secretary and guardian angel. His office manager. She was an ample, beautiful woman with white-streaked hair, dimples, and kind eyes, about sixty, and he dreaded the day she would retire. He didn’t like to think about it. He never spoke of it, hoping that if he didn’t bring it up, neither would she.

  “Good morning, Izzy.”

  “Good morning, Sam.” She gave him a sharp look, as if inspecting him for damage, as she always did around this time of year.

  “She didn’t show,” he had told her briefly last week. She had said nothing, just looked at him with grief-filled eyes, then nodded and handed him his tonic, a stack of pink telephone slips. She did so again this morning with her customary adden
dum.

  “Your breakfast is on its way up,” she said briskly. “Here are your phone calls, urgent on top. Dr. Winkler called twice, wanting to know when you’re going to schedule his patient.” She gave him another glance, then a quick flash of her dimples.

  He nodded and made for his office. He passed Karen, his physician’s assistant. She was already on the telephone. A few of his other partners’ offices were occupied. Barney’s was still dark and empty. After the first few years of keeping a frenetic pace in the practice, Barney had adopted a different philosophy. He had taken Sam out to supper and seriously informed him of it several years back.

  “My work is important,” he said, “but so is my life. I’m not going to give up one for the other. Neither should you,” he had added, apparently unable to resist. Sam supposed Barney had earned the right. He was a good friend as well as a supremely gifted physician. He was older than Sam by ten years or so and had been the front-runner for marquee surgeon of the hospital before Sam had come along. He had exhibited little jealousy or petulance when Sam had come in and assumed that role, in fact, he had become one of Sam’s strongest supporters. During their dinner he had actually thanked Sam. “I want a life,” he had said. “I’m thankful you came along.”

  Sam sat down at his desk. He cleared his mind of everything other than the cases in front of him. He read the charts and brought up the echocardiograms on his computer screen. He watched the blood surge and ebb, mentally picturing what he would do to correct God’s mistakes. He looked at one sent over by a colleague requesting consultation. Maybe you’ll touch this one, Sam. Let me know what you think, the note said, and Sam stared. Sometimes colleagues would send him their hopeless cases, and sometimes he would fix them. He used to look at these cases as challenges. But today, somehow, sending yet another one his way seemed a cruel thing to do. He stared at the screen, at the echo the other doctor had sent. It was of a hypoplastic left heart, further mangled by a botched repair, and Sam felt a surge of pure hatred for the doctor who had botched the surgery instead of referring it to someone who could do a competent job, and for the doctor who had sent him the detestable pictures. And for just a moment, for the briefest of seconds, for the God who allowed all this to go on.

  He stared bleakly at the wall, but oddly enough, he remembered something Ricky had said when Sam had needled him about making his living delivering babies for young women and prescribing hormones for the older ones. “That’s all right, bro,” he had said, smiling his easy smile. “I know it’s not the fast lane, but I could never do what you do. I can’t stand to see sick children.”

  “I can’t stand to see them, either,” Sam had snapped back. “That’s why I fix them.”

  He thought of Ricky, a spurt of life and refreshment, and of the plaque in his office. A baby is God’s opinion that the world should go on, it said. A nice sentiment, but he supposed he had seen too much of the other side. He stared at the wall, then startled when Izzy called his name. “They’re ready for you on the floor,” she said, poking her head around the doorway.

  He nodded and stood to leave.

  He jotted a note on the chart of the child with the botched repair. Yes. I’ll see the child, he scribbled. Perhaps it was hopeless, but he would see what he could do.

  He headed toward the PICU for rounds.

  ****

  It was only seven, yet his office was in full swing. The telephones were ringing, patients checking in. He crossed the hallway and saw the cluster of doctors and students hovering around a tiny bed. They would visit each patient in the unit. Sam joined them, quickly checking today’s lab reports and numbers. He listened to the others’ comments, then added his own. He carefully controlled his thoughts, refusing to think of these tiny patients as infants, children, connected to tubes and monitors. He narrowed his vision to their status, to formulating his recommendations for the plan of action.

  They paused long at the bed of Evan Ridgeway, a three-month-old boy who had never known life outside the PICU of this hospital. His heart had begun to fail even before he was born. Another complex malformation. His heart was an inefficient sponge, vessels and chambers perversely and randomly placed. His only hope was a transplant, and that seemed remote now, as he had turned septic. He would be taken off the transplant list unless his condition improved, which was unlikely. The resident ran down each failing system.

  “I’ll talk to the parents about withdrawing support,” the resident said.

  The rest nodded. Sam clenched his jaw. Barney gave him a quick glance, then flicked his eyes back to the chart in front of him.

  Rounds were finally finished. He went to surgery. He hung his suit carefully in his locker, put on his scrubs, took off his watch, and set it on the shelf. He stared at his bare ring finger for a moment, then closed the locker and spun the lock. He went into the surgeon’s lounge, put on his cap, mask, booties, loupe glasses, his fiber-optic headset, then went into the washroom to scrub. He worked methodically. Each finger, four sides, three minutes. Up, down. In between. Now his forearms. He scrubbed without haste, with thorough method. His mind was narrowing down, sealing itself off to the world beyond, the day outside, the hall outside, even to any part of himself that wouldn’t be needed in the next hours. He didn’t speak, and no one spoke to him. They knew not to. When it was time to do a surgery, he entered into a special universe that had room for only two people. Himself and the child on the table.

  He thought about what he would do for the TGA repair. Rehearsed it. In the normal heart the two sides worked in beautiful symbiosis. The right side took blood returning from the body, full of carbon dioxide and depleted of oxygen, and pumped it via the pulmonary arteries to the lungs, where the blood swapped carbon dioxide for oxygen. It then returned to the left side of the heart via the pulmonary veins, where it was pumped out into the aorta and through the body.

  In the case of the child who awaited him, a three-day-old girl named Elise Sanders, the pumps were connected in reverse. The aorta emerged from the right side of the heart, causing the poorly oxygenated blood to be circulated to the body instead of the lungs. The pulmonary arteries took the oxygenated blood back to the lungs instead of to the body. She was a beautiful child and had looked deceptively normal at birth, not showing her distress until the normal newborn opening between the chambers of the heart had closed, preventing even the minimal mixing of oxygen-poor blood and oxygen-rich blood. In Elise’s case the cardiologists had created a new hole in the cardiac catheterization lab, using a tiny balloon to pop a hole in the septum. Sam would repair this today, as well.

  He entered the theater, hands held up at the elbows, dripping. The chief surgical fellow and his physician’s assistant had already opened and exposed the heart. His eyes scanned the operating theater. The child was ventilated, lines in the jugular vein, the foot, the arm. Blood was hanging. The perfusionist was ready with the heart-lung machine, the magical invention that allowed the heart to quit pumping so Sam could do his work. They were an odd-looking group, he supposed, only their eyes showing. Everything else was covered by hospital aqua. Anything that spoke of individuality was gone. For the next few hours they were extensions of him. His extra hands and eyes.

  The circulating nurse handed him a sterile towel, helped him into a gown, held out his gloves. He walked toward the table, his mind in the other realm. His operating theater was silent. There was no music. No chitchat. He went over the operating plan he had devised in his mind. He greeted his team with a nod. They didn’t expect more.

  He went to work. He marked where he would attach the coronary arteries onto the pulmonary artery, then inserted the bypass cannula. The machine began, its soft shushing taking over the frenetic beat of the infant’s heart. The anesthesiologist gave the heart a dose of potassium solution, and it stopped beating. For a moment Sam’s stopped, as well.

  There it was again. That hesitation. What am I doing? a part of him screamed, looking at the tiny, still organ waiting for his blade. He breathed deeply
and began to work.

  He cut the aorta, sliced it clean through. He cut off the coronary arteries. He cut the pulmonary arteries, and then absurdly remembering his mother’s kitchen and the group of hens who stitched quilts, he began to sew. The coronary arteries onto the pulmonary. The pulmonary onto the aorta. He made a neat repair of the hole they’d made in the septum, taking care with his stitches, remembering hearing what his mother had said to Annie and his sister. “Make your stitches even, girls. Too loose and everything will flop every which a way. Too tight and it will pucker up.” Well, it was the same here. He worked quietly, swiftly. He finished.

  “Off bypass,” the perfusionist said. Sam held his breath. The moment of grace appeared. The heart quivered briefly, then began to beat. He let out his breath slowly. Everything was in order, he reassured himself, his eyes flicking quickly over the surgical site. Everything was where it should be. The right ventricle was now pumping blood to the lungs. The left ventricle to the aorta and to the body. He stared for a moment, silent, as if waiting to make sure it was not some cruel joke, that things would not suddenly come unglued. They did not.

  “Thank you all,” he finally said, signifying the end.

  They murmured back.

  He shed his gown and left the OR, and it wasn’t until he was out in the corridor that he drew a deep, long breath. He felt the adrenaline drain out, leaving a sucking fatigue in its wake. It was at this point he used to thank the Almighty. He didn’t do so now but felt a surge of gratitude nonetheless that disaster hadn’t visited today.

  He thought of the hundreds of surgeries he had done, of the relatively few complications, but he had the sense that his luck had run out years ago and he had been holding things together through sheer willpower. He recalled that once he had thought he was magic, charmed. Blessed. He had believed that he had healing in his hands and that everything he touched would be put right. Well, he knew better than that now, didn’t he? He turned the corner to the lobby to speak to the child’s parents, and the weariness became even deeper. They rose at his appearance, brought their hungry eyes to him, their gaping hearts.