“Look, Alex, if I should have to amputate the arm, I’m not going to have any time to anesthetize you. Once the arm’s numb, I can do whatever is necessary without worrying about further anesthesia.”
“Never thought about that.” Alex patted him good-naturedly on the hand. “I guess surgeons are good for something.”
“What about the prep? What are the possible sources for contamination?”
“The skin for one. The air. The catheters.” Alex thought for a moment. “And, of course, the pump.”
“We’ll scrub the skin with phisohex and zephiran and paint it with an alcohol-iodine solution. In this kind of situation, we’ll use adhesive plastic drapes to cover the entire field. I’m certain the OR here has ultraviolet lights, but they’re no damned good for sterilizing the air. The catheters are pre-sterilized in sealed packages. Paul Ryder will take care of the pump; but you know the problems in sterilizing it. We’ll have to settle for the best we can get there.
“Alex, just go over the indications for amputation once again, will you? I want to be sure I have them straight.”
“What we’re trying to do is to study the organism in vivo, using the arm as an isolated living human system. We’ll try to identify the organism by taking serial samples of blood from the inserted catheters; hopefully, we’ll have a chance to study the bug if and as it changes in the body. Also, we’ll evaluate means of therapy by injecting antibiotics after we draw the samples for the cultures. But if we can’t get rid of the bug with any antibiotics, we can just get rid of the whole system—by amputating the arm.”
“Kind of a ‘gusty’ experiment, isn’t it?”
“Let’s not go into all that again. It has to be done. Besides, I’d rather lose an arm than my life. Anyway, John, there are two indications for amputation. First, if the bug leaks beyond the limits of the system. In that case, do it quickly to prevent more organisms from spreading into the general circulation. If that probe of yours shows a leak, don’t think—just amputate. Second, after the experiment’s over, if the drugs haven’t worked, you’ll have no choice but to amputate—but then you’ll have more time.”
“How are you going to know if there are bacteria left at the end of the experiment? Certainly you can’t culture bacteria in that short time?”
“Of course we can’t, John. But we’ll run a line from the venous catheter through a photoelectric counter with special magnetic grids—something like a white blood cell counter. It’ll give us a continuous reading of the number of bacteria in the venous blood. If the drugs work, the number won’t increase. It can’t necessarily differentiate between live and dead bacteria; but if the bugs are being killed, they won’t reproduce. We can tell if we’re successful by the curve the machine gives us.”
“What antibiotics will you be using, Alex?”
“Five hundred milligrams of murocillin and a gram of ampholysin, each dissolved in 100 cc. 5 percent dextrose and water and injected intravenously over a ten- to fifteen-minute period. Murocillin first, then the ampholysin. The rapid injection will give us peak blood levels in fifteen to thirty minutes.”
John Keith thought for a moment or two. “I guess that about wraps it up. Who makes the final decisions about any problems once we’ve started?”
“You, Sam Ross, Warren Tracey and myself.”
“And what if we don’t agree about something, Alex?”
“Then my decision is final, John. I want that to be clearly understood. If I can’t make decisions for some reason, then you’re the boss; you’re more qualified to make medical judgments than Sam or Warren. I’m counting on your reputation as a person who can make difficult decisions under stress. I asked for you because you’re supposed to be the best goddamned surgeon around. Prove it. Just keep uppermost in your mind that I’d rather lose the arm than my life. Now, when will you be ready to begin?”
“As soon as Paul has the pump set up—in about two hours.”
“Fine.” Alex’s watch said 10 a.m. “Let’s start the party at noon. Everyone will just have to eat lunch early today. I’ll send out the invitations.”
“Don’t you eat, Alex. I get nasty when someone vomits on my operating field.”
“You want me to starve? Besides, the condemned man is supposed to eat a hearty last meal. Want me to spoil tradition?” He realized how out of place his own levity was, but who the hell cared?
He glanced at his watch again. It was an odd, frightening feeling. He didn’t know if this wrist would still be his when the hands of the clock swung by these same numbers again—he didn’t even know if he would be alive at this time tomorrow. A faltering step could be his last.
* * *
Alex walked around the parade ground once more while the others ate lunch. He had no desire to watch them eat. The experiment was due to start in thirty-five minutes—he’d never been a clock watcher before, but time had become a very important variable in his life since his arrival at Fort Detrick. It seemed as if he’d always been there. His life before that seemed unreal now.
He looked out at the peaceful hills again. The sky was still blue, the wispy clouds still overhead.
He walked over to the flagpole and sat down at the base. From here he could see the main gate. The MP’s booth was a mass of broken glass and bullet-riddled boards. The asphalt street, too, was pitted with bullet holes, and metal shell casings occasionally sparkled in the sunlight amidst the ruins. A small group of men in fatigues was still cleaning up.
“Dr. Kahn!”
Alex turned and recognized one of Marion Slade’s aides running toward him.
When Alex walked into the conference room, the general handed the telephone to him and smiled. “Someone wants to talk to you.” Slade picked up his gold-braided hat and left, closing the door quietly behind him.
Still puzzled, Alex put the phone to his ear.
“Dr. Kahn speaking.”
“Alex?”
He hadn’t heard the voice for so long.
“Lori?”
They talked. Into fifteen short minutes, he crowded what he had to tell her while there was still time. The sudden crisis in their lives, the worry and the fear enabled him to say all the things he now knew he should have said before. Only what he was about to do remained unsaid. This would wait for later—if there was a later.
He put down the phone and felt a sudden closeness to Marion Slade. This was not the gesture of a professional soldier, the military robot, but one that only a warm and feeling person could make.
He looked at his watch again: time to go. But he felt better. For those few brief minutes, the telephone had been his link with the real world outside the fence. He knew Lori and the children were well, and he was at peace with himself. When and if this was over, they would be waiting for him.
Alex stared up at the ceiling and blinked at the bright reflector that covered the large, circular operating-room light suspend above him. It was uncomfortable lying on his back with both arms extended at right angles.
Inserted into the vein in his right forearm was a stainless steel needle through which an intravenous solution of nine-tenths percent saline dripped slowly via a coil of thin polyethylene tubing. This was a “safety access” to his central bloodstream should some emergency medication have to be administered rapidly.
His left arm was more uncomfortable, as John Keith, his features barely visible behind the light-green surgical cap and mask, scrubbed it vigorously with phisohex, an antiseptic soap solution, and warm water.
Sam Ross and Warren Tracey worked behind the surgeon, their faces similarly covered. Both wore light-green scrub suits that looked like poorly fitting pajamas. The bacteriologist checked to be certain he had all the necessary culture media and anaerobic equipment. Tracey, his back to the operating table, fidgeted with the dials on a battery of electronic consoles to be used for monitoring the central venous pressure, the arterial pressure, the electrocardiogram, the electroencephalogram, and a variety of other parameters used in specialized surgery.
Alex was startled by the sudden, smarting coldness of the alcohol-iodine solution as John Keith began the second part of the surgical prep. He turned his head to the left and watched as the surgeon carefully painted his skin with the yellowish-brown antiseptic.
“Maybe you should anesthetize the arm before you put that damned alcohol on, John. Man, would you have made a lousy barber! You must have nicked me a dozen times,” Alex kidded him.
“Just keep talking like that, Doc, and I’ll slip some pentathol into that IV,” he nodded to the needle neatly taped in place in Alex’s right arm. “I just love talkative patients.” His eyes smiled sarcastically. “Or better yet, I’ll do the whole thing without anesthesia.”
“You win, John. Can’t fight in this position.”
The surgeon applied the transparent adhesive drapes to the cleansed area. “Help me change gloves and gown-up, will you, Warren?”
Warren stopped his work on the electronic panels and came over to help the surgeon strip off the rubber gloves, now contaminated from the cleansing procedures. He opened a folded surgical gown and allowed Keith to pick it up by the corners, being careful not to touch that part of the gown that would come into contact with the patient. As Warren held up a pair of new, sterile rubber gloves, Keith slipped in his hands; then he walked behind the surgeon to tie his gown.
“If you’ll just open that pack on the Mayo stand for me, Warren, I can do the rest. Also, will you get the catheters for me from Paul?”
Warren peeled off the tape that sealed the surgical pack. Unfolding the green wraps by touching only the under-surface, he avoided contaminating any of the surfaces or equipment the surgeon would need to handle.
The catheters were wrapped in double cellophane envelopes. Warren separated the ends of the outside package of each and let the inner, sterile package drop onto the covered Mayo stand, a large, flat, stainless steel tray attached to a curved, vertical stand on the floor which made it possible to move the tray over the operating table within the surgeon’s easy reach.
John Keith took careful inventory of the instruments and equipment and rearranged them for his convenience.
There was a pile of sterile green towels for draping the operating field: one had a circular opening in the center for access to the area in which he would cut. There were two neatly arranged piles of gauze sponges and scalpel handles and scalpel blades in a variety of sizes and shapes. There were rows of a variety of stainless steel instruments, including straight and curved scissors, clamps, hemostats, smooth and saw-toothed forceps, and several needle holders. Transparent plastic packages containing black suture material lay beside needles for sewing. A pyrex shot glass contained hypodermic needles; glass syringes and plungers lay next to an empty shot glass for liquid anesthesia or antiseptic solution. The remainder of the tray was covered with test tubes and plastic syringes to be used for the many blood samples to be taken.
The surgeon was satisfied that everything he would need was readily available. He draped his field with the green towels and clipped them in place with special snaps. “Everybody ready? Sam? Warren? Paul? Shall we start, Alex?”
Alex Kahn looked around. Over their surgical masks, four pairs of eyes wished him luck. “Let’s go.”
“Hold the xylocaine, will you, Warren?”
Warren took a small rubber-stopped bottle of the anesthetic from a shelf and held it up so John Keith could check the label. The surgeon attached a small needle to the first syringe and filled its body with air. He waited for the top of the rubber stopper to be cleansed with alcohol, and then he plunged the needle through the stopper of the bottle and injected the air. The pressure caused the syringe to fill with the colorless solution. He held it up to the light to check the volume, squirted a little into the air, picked up a gauze sponge, and glanced up at the clock on the wall. “Mark it down, will you, Paul? First anesthesia at 12:45 p.m.” The levity was gone from his voice. This was serious business.
Alex felt a small pinprick and a fleeting sting as the surgeon made a small wheal of xylocaine in the skin high up on the inner arm in line with the major nerve trunk he would anesthetize next. With the exception of another second of stinging, Alex felt no pain. John Keith continued to infiltrate the area, slowly allowing the anesthetic to numb the nerve endings before advancing the needle farther in each direction. He withdrew the needle, and Warren helped him fill a second syringe with xylocaine, replacing the small needle with a thin one about six inches long. When he reinserted it, he was careful to puncture only the previously anesthetized skin so that Alex felt no pain.
He paused for a moment. “This will ache a bit, Alex. It’s the big one; but the whole arm will go numb. Then you can sit back and watch.”
He adjusted the angle of his thrust and plunged the needle to the hub upward and inward.
Alex winced at the severe, aching pain. It felt as if someone had just torn his arm off at the shoulder. His arm felt warm as the sting of the injection subsided, and it began to tingle with the sensation of pins and needles. In about thirty seconds, he could feel nothing distal to the left shoulder. It was an odd sensation. He looked to be certain the arm was still there; it seemed to belong to someone else.
“Feel anything?” John Keith tested the adequacy of the anesthetic block by pricking here and there with the point of a needle.
Alex shook his head.
The surgeon then inserted a blade into a scalpel handle and picked up a pair of forceps. Leaning over the part of the arm visible through the window in the drapes, he cut through the plastic covering. With the forceps, he pulled aside the adhesive protective covering to expose only the small area in which he would work. He discarded the now-contaminated, used instruments and picked up a sterile blade and handle for the incision through the skin.
Alex watched him work. His steady hands literally flew; and their clean, smooth motions reassured the observers about his surgical skill and flawless technique.
With a single motion, he made a clean, straight, two-inch incision through the skin, the subcutaneous tissue, and the thin layer of fat. As beads of blood welled up along the cut edges, he quickly sponged them dry and stopped the bleeding with small hemostats. When several bleeders had been clamped, he stopped to tie them off before going further. The wound appeared sharp and clean. With forceps and the blunt end of a curved clamp, he pushed the connective tissue aside and exposed the glistening surfaces of the walls of the major artery and vein to be catheterized. Unlike artist’s sketches in which the artery is painted red and the vein blue, there was little gross difference between the two when seen in the living person. The artery was recognizable by the visible and palpable pulsations; the vein, by the slightly darker hue of the blood as it flowed back toward the right side of the heart and from there to the lungs for oxygenation. With blunt dissection, the surgeon exposed and freed up about two inches of each vessel.
Then Keith paused to open the sterile inner packages that contained the catheters, examining each to be sure it was intact. He chose two that appeared to be the correct size.
Before Alex could decide exactly what was going on, the catheters were neatly in place to occlude the vessels and were connected to the tubes leading to the pump-oxygenator. When this was done, Keith checked the flow of blood with his eyes and finger to make certain that the system was operating properly. All was in place.
Stopcocks were placed at the various junctions between the catheters and the tubes leading to the pump into which a syringe could be inserted to inject fluids and withdraw blood samples.
With another deft motion, Keith inserted the monitoring probes and had Warren Tracey attach them to the monitor on his electronic panel.
John Keith viewed his work with satisfaction. The entire procedure had taken thirty-five minutes. “We’re all ready to go any time you are, Alex. How do you feel?”
“Fine, John. Man, ar
e you fast! I’m ready if everyone else is.”
Each motioned that he was ready to start the rest of the experiment. Sam Ross held up a small, sealed flask of cloudy broth containing the organism, as if to signal it was ready for injection.
John Keith injected 10 cc. of a greenish-yellow fluid into the arterial catheter stopcock.
“What’s that, John?” Alex tried to lift his head to see what the surgeon was doing.
“It’s the dye for monitoring for leaks. Put your head down. If the system isn’t closed, it may make you feel light-headed and warm. Feel anything?”
“Nothing.”
“Good. The system is sealed.”
For the next several minutes Keith obtained blood samples. Then he turned to Sam Ross. “Ready for the bug, Sam.” He turned back to Alex. “Last chance to chicken out, Alex. What do you say, Doc?”
“Let’s get on with it. I’m hungry.”
By means of a carefully constructed closed siphoning system, John Keith was able to fill a syringe with the suspension of the organism without contaminating his sterile gloves or exposing himself or the others to the deadly solution.
Paul Ryder checked the readings on his board, Warren Tracey the equipment before him, and John Keith the system of tubes and catheters through which blood was flowing smoothly. Consciously or unconsciously, each hoped he would find something wrong, something missing, which would preclude continuing this dangerous experiment. But all was functioning properly; everything was in place; there was nothing to stop them.
“Here we go, Alex. God help us, I hope we’re doing the right thing. I hope this damned experiment tells you what you want to know.”
As if he were afraid he would change his mind if he hesitated, John Keith swiftly attached the syringe to the arterial stopcock, opened the valve, and injected the entire contents into the arterial system in one smooth motion.
It was done. There was no turning back.
Alex Kahn glanced up at the wall clock. Two p.m. The bacteria had been circulating in his arm for thirty minutes. With the exception of a two-degree rise in the temperature of his left arm, almost no demonstrable changes had occurred. The counter showed the presence of the organism in the blood and the expected increase in numbers as it multiplied.
The 11th Plague Page 15
