by Robin Cook
I closed the door and started down the long passageway to my room. It was all too true — all the things I had thought about myself in those seconds after he said Karen's name. I was a cold, detached son of a bitch and getting more so. Everything I thought about confirmed it. My initial relationship with Carno, for instance; it had just disappeared in a disguise of inconvenience. In fact, I had been too selfish and lazy to keep it going. Surfing was probably the biggest cop-out of all, especially since I apparently was using it to cover and relieve my progressively isolated life. And Karen herself — a vacant and meaningless relationship if ever there was one. Feelings I had vaguely noticed, the emptiness and undirected yearning — I had sought vainly to repress them by encounters with Karen and Joyce, even Jan. Much of this became horribly clear to me as I sat in the chair in my dark room, searching for answers.
I hadn't always been like this. Not in college, where friends had come easily and stayed. And the lonely yearning so much a part of me now? Perhaps a little during the first year of college, but not after that. Medical school had come next. Had the seeds of change been planted there? Yes, after all, it was during medical school that friends had drifted away, and attitudes and practices with women had changed, out of necessity, driven as I was by hard economics and limited time. But not until internship had the seeds of change germinated. Now I was sexually and socially little more than a cruiser, except that I operated in a hospital rather than the real world. How different it had all turned out. The phone rang, but I ignored it. Taking off my whites, I put on some wheat-colored jeans and a black turtleneck.
Why had this happened to me? Was it only the schedule? Or that combined with the fear and anger always inside me? Was it basically my self-disgust at not speaking up when I believed the system was rotten, at letting myself be carried along nevertheless, holding it all in? Was my brain so warped by exhaustion it was no longer logical? I didn't know. The more I thought, the more confused and depressed I became. Confused about causes, not effects. In perspective, the effects were clear: I had become a real bastard.
Suddenly, I thought of Nancy Shepard, of how I had pushed her out of my mind, rejected her questions and accusations. That night we argued, she had been trying to tell me what I had just learned from my therapist — my therapist, the schizophrenic. What a triangle, I thought: a double-dealing nurse, a barely compensated schizophrenic, and a screwed-up intern. Nancy Shepard had called me an unbelievable egotist, a selfish blob working toward a point at which love would be impossible. And she had been right. What did it matter that there was more to it; that it was not innate in my personality, but developed; that I had been encouraged, day in and day out, to avoid genuine emotional involvement because to do so was the only natural defense I could conjure up to deal with the anger, hostility, and exhaustion? What did it matter that an intern's routine was senseless monotony, or that the medical system was designed to use and harass him? To a Nancy Shepard — to anyone — the end personality result was all that mattered. She had brushed me lightly with some truth, and I had kicked her out of my life for her pains.
Lying down on the bed, I wondered what to do now. For the moment, sleep. How many bridges did I still have standing? And Karen? I didn't know. Maybe I'd see her, maybe not. I hoped I wouldn't, but I knew I probably would.
Day 365
Leaving
The appendix lay to one side in a steel dish, where I had put it a moment earlier before turning back to the operating table. The surgeon was finishing sewing up the stump where the appendix had been. Our concentration was so intense that neither of us saw the hand until it crept into the operative field and began groping aimlessly around, palpating the fleshy, moist intestines. The hand was ungloved — most definitely out of place in our previously sterile operative field. It seemed to be a foreign thing from the twilight zone beneath the surgical drapes. The surgeon and I looked up at each other in alarm, and then at Straus, the newly arrived intern, but Straus couldn't take his eyes off the hand. The next few seconds whirled in mental confusion as the three of us strove to connect the intruder with one of the operating team. Just as I dropped my needle and thread and was reaching to pull the hand away from the incision, the surgeon figured it out. "For Christ's sake, George, the guy's got his hand in his belly!"
Awakened from his reverie, George, the anesthesiologist, poked his nose over the ether screen and commented, "Well, I'll be damned," in a noncommittal sort of way, before dropping back on his stool. With a deftness that belied his apparent torpor, he injected a potent muscle-paralyzing drug, succinylcholine, into the IV tubing. Only then did the patient's hand relax and fall back onto the surgical drapes.
"When you said you'd keep the patient light, I never thought I'd be wrestling with him," said the surgeon.
Instead of answering, George eased off on the succinylcholine IV with his right hand while his left opened the tank of nitrous oxide a few more turns. After several forceful compressions of the ventilation bag, to speed the nitrous oxide into the patient's lungs, George looked up to join the fray.
"You know, George, this epidural anesthesia of yours is good fun. Puts the challenge back in surgery. In fact, this case is exactly like a sixteenth-century appendectomy."
"Oh, I don't know," George retorted. "Back then the patients not only attacked with their hands; they kicked, too. Have you noticed how quiet his feet have been? We're making a lot of progress in anesthesia."
As such sallies went, this was a pretty heavy barrage, and the surgeon decided not to return fire. Instead, he directed his attention toward salvaging what he could of the operative field. While he kept a precautionary hold on the patient's troublesome hand, I covered the incision with a sterile towel soaked in saline. Straus and the scrub nurse and I were still sterile, as the OR terminology put it.
Breaking the sterility of the operative field was a serious problem, because it greatly increased the probability of post-operative infection with something like a staph. Some surgeons are quite maniacal about sterility — but never, it seems, in a consistently rational way. For instance, one professor in medical school required interns, residents, and students to scrub for exactly ten minutes by the clock. Anyone trying to get into the OR after a scrub of less than ten minutes had to start over from the beginning. These strictures did not extend, however, to his own scrub, which lasted, by generous estimate, no more than three or four minutes. Apparently the others' were more contaminated, or his bacteria less tenacious.
His fastidiousness about sterility had been responsible for one memorable episode. The case was an interesting one, involving a bullet wound of the right lung, and residents and interns were three deep around the OR table. One resourceful medical student a rather short fellow, was intent on seeing every detail. He piled several footstools on top of each other, stood on them, and by holding on to the overhead light for support, could lean over and gaze directly down into the operative field. This ingenious vantage point worked well until his glasses slid off and fell with an innocent plop directly into the incision. This had so unnerved the professor that he directed the resident to continue the case.
Luckily, Gallagher, the surgeon for the appendectomy, had a firmer grip on his emotions than the medical-school professor had. Though obviously upset, he was still functioning.
"George, see if you can pull this arm out from under the drapes and hold it securely," Gallagher said, looking over at me and rolling his eyes at the absurdity of it all as the anesthesiologist burrowed headfirst under the sheets.
"And, Straus, you just back away from the table," I said. Poor Straus was obviously confused. His eyes moved back and forth from the surgeon, still grasping the patient's hand, to the trembling mass of drapes that indicated the anesthesiologist's progress, or lack of it." "Just fold your hands, Straus, and keep them about chest level." Straus backed away, grateful for the instruction.
With some difficulty, the anesthesiologist worked the patient's hand back into its proper position and attempt
ed to secure it flat on the operating table. Then the surgeon stepped back and allowed the circulating nurse to remove his gown and gloves, while the scrub nurse descended from her footstool with a new, and sterile, replacement set.
What a way to end my internship, I thought. This was my last scheduled scrub as an intern — perhaps my last time in the OR as an intern, although I was scheduled to be on call that night and could get some after-hours surgery. Anyway, this case had been a circus right from the start. For one thing, the patient had been given breakfast because I had forgotten to write "nothing by mouth" in the chart, and the nurses, who should have known better, what with all his other preoperative orders, had missed it, too.
"Straus, help me with the sterile drapes." I leaned across the patient and held one end of a fresh sterile drape toward the new intern. We were overlapping by one day — his first and my last. I was still officially an intern, although I suppose I had been acting more like a resident since all the new interns arrived. They seemed a good group, as eager and green as we had been. Strauss and I had been scheduled together so I could help him get acquainted. In fact, we were on joint call that night.
"Hold it up high," I directed, raising my end of the drape to about eye level and letting the edge cover the old drape. "Good. Now let the upper portion fall over the ether screen." He seemed to catch on easily, and I gave him the lower drape. But the surgeon, now freshly gowned and gloved, was impatient, and he took the drape from Straus, helping me to complete the redraping rapidly and without another word.
It was two-fifteen by the large clock with its familiar institutional face. I could not comprehend that within twenty-four hours I would be leaving my internship behind. How rapidly the year had passed. Yet some memories seemed older than a year. Roso, for instance. Hadn't he always been a part of me? And…
"How about a little help, Peters?" Gallagher was already brandishing a needle holder that trailed a fine filament of thread from the tip. But he couldn't begin because the sterile towel I had draped over the incision was still in place.
"Large clamp and a basin." I reached toward the scrub nurse, and she crashed a clamp into the palm of my hand. She was a demon when it came to OR procedure. Apparently she had been watching a lot of television, because she cracked the instruments into your hand almost to the point of pain, and when she gloved you it was as though she was attempting to stretch the glove all the way to your armpit. Using the clamp, I removed the sterile towel without otherwise touching it and plopped it into the basin. The concept of OR sterility baffled me to the point that I always erred on the safe side. I didn't know if Gallagher thought the towel was contaminated, but, to be sure, I didn't touch it. Of course, with the patient rummaging around in the wound with his bare hand, all this procedure was nonsense.
The towel out of the way, Gallagher returned to the appendix stump. Luckily, the patient had chosen a good time for his antics; not only had the appendix been removed, but the stump had also been inverted. Gallagher had been nearly ready to put in his second-layer closure over the area when the mysterious hand appeared.
George, the anesthesiologist, had made a fantastic recovery. Things were already back to normal over his way — the sound level of his portable Panasonic was competing with the automatic breather that had been brought in after the succinylcholine. This was not a mere precaution. Succinylcholine is so powerful that the patient was totally paralyzed now, and the machine was breathing for him. As Gallagher took the first stitch after his arm wrestle, the general atmosphere returned to precrisis level. We even paused to listen when the surf report drifted out of George's radio over the ether screen—"Ala Moana three-four and smooth." But my board had already been sold. Gallagher was one of a couple of the younger attending surgeons who occasionally surfed. I had seen him a few times at "number 3's" off Waikiki, and he was definitely a better surgeon than surfer, being rather dainty at heart. He had a telltale habit of picking up surgical instruments with his little finger stuck out, the way a flower-club lady holds a teacup.
That was the way he took the next stitch— extending his pinky as far as possible from the rest of his fingers and deftly trailing the silk out of the needle holder into my waiting hand. Since I was the first assisting, it was up to me to tie. Straus was holding the retractors. The first throw was formed and run down extremely rapidly, as happens when an act has become reflexive. The opposing walls of the large intestine came together over the inverted appendiceal stump. As I tightened the suture, Gallagher pretended not to watch, but I was sure he had an eye cocked. Since he didn't say anything, I guess he approved the degree of tightness I placed on the first throw. Then he took the freshly loaded needle holder from the scrub nurse as I started the second throw.
"Hey, Straus, how about lifting up a little on those retractors so I can see my knot?" It bugged me that Straus was staring off into space just then. I held up running down the second throw while he looked into the wound and lifted with his right hand, opening the wound wider. That made it possible for my right index finger to carry the fold of thread down until it matted with the first throw, where I tightened it with a precision that seemed to me exactly right. Another throw, but with my other hand leading, so the knot was sure to be a square knot, not a slippery granny.
Five such sutures completely covered the appendicial-stump area, and we were ready to close.
"Straus, you did a fantastic job," said Gallagher, winking at me, as he took the retractors from the new intern. "Couldn't have done without you." Not really knowing if Gallagher was putting him on, Straus wisely elected to remain silent. "Where'd you learn to retract like that, Straus?"
"I scrubbed a few times in medical school," he said quietly.
"I was sure of it," returned Gallagher, a supercilious smile creeping from the sides of his mask.
"Peter, can you and our young surgeon here close the wound?"
"Yes, I think so, Dr. Gallagher."
Gallagher hesitated, looking at the incision. "On second thought, maybe I'd better stay. If the patient gets a postop infection, I want as few people to blame as possible — just George. George, you hear that?"
"What’s that?" George looked up from his anesthesia record, but Gallagher ignored him and stepped back to rinse his hands in the basin.
"Straus, how are you at tying knots?"
"Not too good, I'm afraid."
"Well, ready to try a few?"
"I think so."
"Okay, when we get to the skin, you tie."
The fascial sutures went in quickly. My tying now was nearly as rapid as the surgeon's suturing, and the scrub nurse had to hustle to keep up with us. The smiling wound came together as the subcutaneous sutures were placed and tied.
"Okay, Straus, let's see what you can do," said Gallagher, after placing the first skin suture in the center of the wound and trailing the silk thread out over the patient's abdomen. The first skin suture, in the center of a wound, is the hardest, because until the adjacent sutures are placed it bears a lot of stress, and the stress makes it hard to tie with the correct tension. Gallagher winked at me again as Straus picked up the two ends of the thread. Straus didn't even have his gloves on tightly, and there were wrinkled bunches of rubber at the tips of his fingers. He didn't look up, though — which was a good thing, because I knew what was coming and my face was contorted in a broad smile of anticipation.
Poor Straus. By the time he got the second throw down, he was perspiring, and the skin edges were still almost half an inch apart. Moreover, he had gotten his fingers all bunched up in the suture in a fashion that suggested he was going through a comic routine. But he still didn't look up, a good sign. He would be all right.
"Straus, you've got the theory right. Skin sutures should not be too tight." Gallagher chuckled. "But half an inch is pushing a good thing too far."
"You guys can take all the time you want. The patient is going to be paralyzed for quite a while with that succinylcholine," added George.
I cut the
gaping suture, pulled it out, and dropped it on the floor. Gallagher flipped in another in its place, detaching the thread from the needle with an almost imperceptible twist of his hand. Straus silently picked up the ends and started fumbling again.
"This isn't the first time I've seen a bare hand in a stomach wound," I said, looking over at Gallagher. "Once in medical school about eight of us students were in the OR trying to see a case, and the surgeon said, 'Feel this mass. Tell me what you think.' The residents all took a feel, nodding in agreement, and then an ungloved hand sneaked between two residents and felt around, too."
"Was it one of the medical students?" asked the anesthesiologist.
"Probably. We never knew for a fact, because we were all thrown out by the chief resident, who was trying to calm the surgeon."
Straus was still fussing with the second suture, dropping the ends, getting his fingers caught, and leaning this way and that in a kind of hopeful body English. I'm not sure how he expected body English to help, but I recognized the same tendency in myself.
"Did the patient get a postop infection?" asked Gallagher.
"Nope. Sailed through without a complication," I said.
"Let’s hope we're traveling the same path."
Without saying anything, I untangled the silk from Straus's hands and rapidly placed a knot, pulling it over to the side so that it was away from the incision. Straus doggedly kept his head down while Gallagher whipped in another suture.
"How about that one, promising surgeon?" said Gallagher, stretching his arms out with his hands inverted and his fingers intertwined. One or two knuckles cracked.
This Straus certainly was a silent fellow; not a sound came out of him as he concentrated on the skin suture. Actually, I was already tired of the game, of watching him fumble around. It was getting pretty close to three, and I had a lot to do, last-minute packing and other details. After a reassuring glance at Gallagher, I again untangled the suture from Straus and laid a rapid square knot, bringing the skin edges together without any tension.
