The Year of the Intern

by Robin Cook

  This new kidney method of Hercules's involved putting a 2–0 chromic suture — a very large thread— through the kidney and then, by holding the suture at both ends and manipulating it somewhat like a blunt knife, sawing back up through the kidney. This was supposed to reduce bleeding. The procedure sounded a bit strange and oversimplified to me. As it turned out, mine was a healthy skepticism. Hercules had forgotten one vital point that the article repeatedly emphasized: before "sawing" with the suture, the surgeon must first gain control of the kidney pedicle — the source of blood to the kidney — so that the blood flow through the organ is essentially stopped. Well, our fearless innovator plunged ahead, making no provision to control the blood flow, but sawing nonchalantly up through the kidney "to minimize bleeding." The result was the worst uncontrolled hemorrhage I have ever seen in an operating room — except for the time the right atrial catheter of a heart-lung machine fell out of the patient. But that was a legitimate mistake. The kidney disaster was not. Blood from the kidney vessels filled the wound instantaneously, overflowing it and soaking the table and all the operating team. We began to pour blood into the man through the IV, as down a deep well. Eight pints later, we had finally clamped down on the kidney, sucked out the wound enough so that the stone could be removed, and put enormous sutures through the kidney cortex. Since the human body holds only about twelve pints of blood, we had practically drained the poor man and filled him up again. It scared hell out of everybody. Even the anesthesiologist — normally in another world up behind the ether screen, with one eye on the automatic breather and both hands on his newspaper — was upset.

  Naturally, then, I wasn't looking forward to this gastrectomy with Hercules, whom I could see inside working away as I scrubbed. I hoped he hadn't read any more current literature. A resident named O'Toole was there, too, but no intern was in evidence. As I backed in, surrendering, I could tell the atmosphere was anything but congenial.

  "I want a decent clamp," yelled Hercules to the scrub nurse as he threw one over his shoulder against the white tile wall. "Peters, get the hell in here. How is a man supposed to do surgery without any help?" Some of these surgeons took a bit of getting used to. Much of the time they behaved like petulant children, especially when it came to the instruments, which they tended to throw around rather indiscriminately and to use in unexpected ways — such as cutting wire with dissecting scissors. Yet the next time they were handed one of these instruments that they might have damaged themselves, they'd stomp and rage, blaming all their recent bungles on a lack of proper equipment. No one ever said anything about these outbursts. You got used to them after a while.

  As I moved in next to Hercules, he clamped my hands around a couple of retractors and said to lift up, not pull back. A familiar line. Actually, I was able to fake it, because there was nothing to retract at the moment. The stomach, which Hercules was working on, sat right on top of the incision in full view. He would need retraction later, while making the connection between the stomach pouch and the beginning of the intestine called the duodenum. I fervently hoped he had already cut the nerves to the stomach that are partially responsible for the secretion of acid. Those vagus nerves wind around the esophagus, and in order for the surgeon to cut them the intern has to hold up the rib cage; I hated that retraction.

  Here I was again at my post in the OR watching a minute hand that appeared to be glued in place. As I fought to stay awake, my eyes blurred after each yawn, and my nose itched uncontrollably on the left side, a little below my eye, as if I were being attacked by a subtle, sadistic insect.

  The position of my mask was another subtle torture. Each time I yawned it moved a little down my nose, perhaps half an inch. After five yawns it fell completely off my nose and was just covering my mouth. This called into play the circulating nurse. She hopped around to my side and lifted the mask up, touching it ever so carefully to avoid my skin, almost as if my whole face were infectious. Wishing to relieve the itch, I tried several times to push my nose against her hand as she adjusted the mask. But she was too quick for me, and pulled away each time before hand and nose could meet.

  Hercules was even more nervous and erratic than usual. None of us around the table could anticipate what his next move might be. Fortunately I was immobilized by the retractors and not expected to contribute otherwise, but poor O’Toole was like a rat in an uncharted maze being called upon to perform impossible feats of anticipation.

  "O’Toole, are you with me or against me? Hold that still!” While delivering this rhetorical question, Hercules gave O’Toole's left hand a sharp swat with the Mayo scissors. O’Toole gritted his teeth and adjusted his grip on the stomach.

  “For Christ's sake, Peters, haven't you learned how to retract?" He grabbed my wrist for about the sixth time to readjust the retractors, even though retracting had nothing to do with what was going on at the moment. In fact, I wasn't needed; yet he wanted me there. He was like a lot of surgeons, who felt slighted if they weren't assisted by both a resident and an intern, regardless of need. I was a status symbol.

  Hercules had rotated in front of me so that I was staring at his back as he began putting in the second layer of sutures on the stomach pouch. I could see neither the operative field nor my own hands.

  The anesthesiologist spoke up rather suddenly. "Peters, please don't lean on the patient's chest. You're compromising his ventilation." He pushed my lower back through the ether screen to keep me from crowding the intravenous line. But I had no place to go, being already mashed up against Hercules.

  Just then O’Toole stepped abruptly back with a startled expression on his face, holding up his right hand. I could see a few drops of blood dripping out of a neat slice through the rubber glove into the side of his index finger.

  "If you had your finger where it was supposed to be it wouldn't have happened, O’Toole. Let’s wake up," boomed Hercules.

  O’Toole said nothing as he turned to the scrub nurse, who slipped on another glove. I guess he was thankful to be still in possession of the finger.

  Despite all, the surgeon somehow finished, and we began to close. One of my jobs was to irrigate with the bulb syringe after the strong, fibrous fascial layer of the abdominal wall had been closed with silk sutures about a quarter of an inch apart. O’Toole and I were feeling frisky by then, and as Hercules was rinsing his hand I raised the syringe up over the wound, over the patient, and shot a stream of warm saline across the table, hitting O'Toole in the gut. Our eyes met in understanding; we were partners in an unhappy situation.

  Rejoining us at the table, Hercules turned suddenly jovial. Obviously, he thought he had accomplished the impossible once again. "If s too bad that my art gets covered up under the skin instead of being visible to the patient. All he has to show is this little incision." O'Toole's eyes rolled up into his head in mock dismay.

  Since both O'Toole and Hercules were on hand to finish up, I marshaled my courage for the exit. "I have several other operations coming up, Doctor. Will you excuse me, please?" That irritated the old boy a little, but he waved me free with a gesture of noblesse oblige.

  First I scratched my nose, long and hard, a sensual experience. Then I urinated, which was equally satisfying. It was eleven-twenty-five, and since the nephrectomy patient was just coming out of Room 10, I had a few minutes while it was being made ready for the first of my cholecystectomies. Nearby, at the door of the recovery room, I saw Karen, my angel of mercy and sex, pristine in her white uniform. She had come to take a patient down to the ward, and when she saw me she smiled broadly, asking with a trace of sarcasm if I had slept well last night. I told her to be pleasant or one of these nights I would roll her out of bed. Glancing around, she shushed me, adding that she had told her boyfriend she didn't want to go out that evening; she would be in, probably from eleven on, in case I was free. I filed the fact away, but I didn't think I'd be up to doing anything about it.

  My aneurysm had been scheduled for his aortogram at eleven-fifteen, and I went d
own to see what was happening. Stepping into the fluoroscopy room, I saw that the chief resident was in the final preparations for the study. "You're ten minutes late, Peters. I could have used you to help get the catheter into the aortic bulb."

  "And I would have been here, but I had to scrub for another case." I consciously withheld a "thanks to you."

  "Well, here's the catheter position. Put on a lead-lined apron first. This fluoroscopy puts out a lot of radiation. Gotta protect the old gonads."

  Following his advice, I took one of the heavy leaded aprons and put it on. By stepping behind him I could see the fluoro screen. As the lights went out, the fluoroscope came on automatically with a low resonant dick. Then image was extremely faint, as usual. In order to see a fluoroscopy well, you ought to adapt your eyes by wearing red goggles for thirty minutes or so beforehand. I couldn't tell very much about the aneurysm patient on the fluoro screen, because I hadn't had the chance to dark-adapt my eyes, but I could distinguish the heavy radiopaque stripe on the catheter.

  "Here's the end of the catheter." The chief resident's pointing finger was silhouetted by the light from the screen. "If s in the aorta just above the heart. See it jump with each heart contraction?" I could see that with no difficulty. "Now, we went to inject enough radiopaque dye into the artery to get an image, and to do that we have to use the pressure injector." He indicated a small machine that looked something like a bicycle pump turned on its side. It had three or four stopcocks positioned on the end — I thought one or two should have been sufficient to prevent a mishap. "All we do is push this handle, which shoots the dye very rapidly into the heart, at about 400 psi. At the same time the Schonander camera will be shooting X rays at a rate of one every half second for ten seconds. We'll watch on the fluoro screen."

  The chief resident swung into the final preparations, calling to make sure the X-ray technicians were ready and positioning himself behind the arm of the pressure injector. Desiring all the protection I could get, I squeezed in behind the lead screen with the X-ray technician, who was a solid little thing. We watched through the quartz window.

  At a yell from the chief resident, the X-ray technician started the Schonander camera, which cranked and pounded, taking X ray after X ray in rapid succession, while die chief resident plunged the pressure injector all the way down. The dye shot from the injector into the stopcocks, and then, instead of being propelled into the patient's heart, rose in a graceful geyser to the ceiling, splattering there and running a little way along before dripping down onto the chief resident, the patient, and the mass of machinery. The chief resident had forgotten to open the last stopcock. As for the patient, he just lay there blinking and looking around, trying to figure out what sort of strange test this was. The chief resident was in a state of shock blending rapidly into exasperation. Since the whole procedure would now have to start over and I was already a little late for the cholecystectomy, I took the opportunity to make an unobtrusive exit and hurried back to the OR.

  Working with a real professional is different in every way from assisting a Hercules or a Supercharger, and Dr. Simpson was the best the hospital had. With the resident on one side of him and me on the other, we scrubbed together, talking and joking. Simpson told us the one about a Columbia professor who discovered a way to create life in the laboratory. Everything went well until his wife caught him.

  A simple joke — perhaps, on reflection, not even a very good one. But in the context of my hours with Hercules, the image of dye all over the fluoro-room ceiling, and my tiredness, that joke plunged me into hysterical laughter. We were still chuckling as the three of us entered the operating room, where the atmosphere changed immediately to one of congenial concentration. Ready to go, we were still light toned, but nevertheless intensely interested in the task ahead.

  The nurse handed Simpson a scalpel. Interesting how he started an operation. There was no pause. The knife shot in to the hilt and zoomed cleanly, diagonally down the abdomen. He didn't pause to catch bleeders with hemostats. "Why scratch around like a chicken?" he would say, completing the incision rapidly, with the same sharp, purposeful dissection, as the tissue fell apart. The resident would then pick up the tissue on his side, the surgeon on the other, both using tooth forceps, and with a final flash of the knife they were into the abdomen. Only then were a few bleeders caught and tied. No more than three minutes from skin to peritoneal cavity. Perfection.

  This time, however, Simpson didn't make the first cut. He surprised us by handing the knife to the resident instead. "Your gall bladder," he said. "One false move and you'll be doing enemas for a month." Under his expert eye, the same kind of incision was made, at just about the same speed. The surgeon explored rapidly inside, then the resident, then me. Stomach, duodenum, liver, gall bladder (I could feel the stones), spleen, intestines. The examination was gingerly but thorough; with your arm elbow deep in someone's abdomen, you tend to be gingerly. I told Simpson I was having trouble feeling the pancreas. He explained a landmark and a bulge. Then I felt it.

  Using Simpson's technique, the resident carefully placed the saline-soaked white towels that are used to separate the gall bladder from the mass of intestines. I was given the usual retractors. At a suggestion from Simpson, the resident moved down a little, enabling me to see into the wound. It all went rapidly, with encouragement but no manual assistance from Simpson. The gall bladder came out cleanly the base was closed, and then the skin, all within thirty minutes. Feeling good now, I congratulated the resident on our way to the recovery room. He had done a professional job.

  With thirty minutes between cases, Simpson and I went down to see several of his patients, one of whom, a gastrectomy, I was following closely after having helped with the surgery. I had been given total responsibility for writing orders on the case, although I tried to follow Simpson's preferences, which, I knew by now, were sound and sensible. When he changed one of my orders, as occasionally happened, he invariably wrote out a short explanation, an opinion on some drug or procedure. He was a born teacher.

  After our trip to the ward, we put on another set of clean scrub suits and began to scrub again, in the same bantering way, this time without hysteria on my part. I decided, on reflection, to switch to Betadine for this scrub; its pale yellow color offered a bit of variety, after the colorless phisohex we usually used. Entering the OR, we observed the usual hierarchic routine. A towel went first to Simpson, then one to the resident, and then one to me. It was the same with gloves.

  As we huddled around the patient, the nurse handed Simpson a scalpel, and to my utter confusion he handed it on to me. "Okay, Peters. Get the gall bladder, and get it right the first time or I'll remove yours without anesthesia." Obviously, I had never done a cholecystectomy before, though I had seen a hundred or more, and this development was definitely not in my imagined scenario. I had looked forward to another session as interested spectator, watching two professionals (the resident had come of age) work together. Now, however, I was to be not a spectator, but a participant — indeed, the chief actor. Suddenly the man on the table and the scalpel in my hand took on new reality. Inwardly awash with uncertainty, I knew that if I hesitated now, I might be too scared ever to try again. I somehow conquered a tremor that threatened to develop in my right hand, grasped the knife firmly, and tried to duplicate Simpson's first slice into the top of the abdomen, going straight in, up to the hilt, then coming diagonally down the blade at a ninety-degree angle with the skin. I wanted to please Simpson as a son wants to please his father.

  "By golly, there's hope for you yet," he said in jest, not knowing how sweet the words were to me. As I repeated the maneuver, muscles and fat parted and, retracted. Some bleeding followed, but not much.

  "Forceps." The nurse gave them to me, and a pair to the surgeon. I lifted one side of the incision, he the other. At this point we were very close to the thin, peritoneal membrane that forms the lining of the abdominal cavity. We were lifting now to protect the underlying organs as I pushed i
n the blade of the scalpel. Pop! A hole appeared in the abdomen, and I let go of the forceps.

  "Keep the forceps," Simpson suggested, "and cut while you can see." I tried, going carefully because the liver and intestines were clearly visible in the widening incision. It worked fine. Then, for the lower end of the incision, I had to change the technique. Dropping the forceps, I slid my hand into the wound and opened the rest of the peritoneum by cutting between my fingers. My heart was racing. I didn't feel tired now, nor did I notice the clock, the radio, or the anesthesiologist. I was scared but determined. Simpson felt around, then I did, then the resident, and the resident took the retractors as I moved down to give him an open view if he wanted it. I also tried to follow Simpson's technique with the abdominal tapes. He helped me with the last one, and then with his hand he rolled the duodenum far enough that I could see a smooth curve of tissue stretching from the top of the duodenum to the gall bladder. After clamping the gall bladder and pulling up, I used the Metzenbaum scissors to push down the delicate tissue. An artery was in there somewhere, the cystic artery, which carried blood to the gall bladder. Mustn't cut it.

  The muscles of my neck were hard as rocks as I bent far over, trying to see clearly. Simpson told me to straighten up or I wouldn't last fifteen minutes. The artery appeared — about the usual size for a cystic artery — and I isolated it with a gall-bladder clamp. A tie went around, and I took the ends. First throw. I ran it down with my right index finger. Good. Second throw. Down. How much tension should I put on the thread? That was enough; I didn't want it to break. One more throw, just to be sure. With the help of the gall-bladder clamp, another suture went around the cystic artery. This time I had to make the tie way down, close to the hepatic artery going to the liver. The cystic artery branched from the hepatic artery, and by pulling slightly on the suture already tied around the cystic artery I could see the wall of the hepatic artery. In fact, I could even see the branch going to the right side of the liver. That made me feel better, because there was always the danger of confusing that bugger with the cystic artery and tying it off.