Authors: Robin Cook
The others were already prepared to go down to the OR. George Niles showed Susan how to put on the paper booties over her shoes and tuck in the conductive tape. Next she put on the hood and finally the mask. Once everyone was so attired, they passed the main OR desk and pushed through the swinging doors into the “clean” area of the ORs themselves.
Susan had never been in an OR before. She had seen a couple of operations through the gallery windows but such an experience was akin to watching it on TV. The glass partition effectively isolated the drama. One did not feel a part of it. While walking down the long corridor Susan felt a certain excitement mixed with fear of the mortality of people. As they passed OR after OR, Susan could see clusters of figures bent over what she knew were sleeping patients with their fragile insides open to the elements. A hospital gurney approached them with a scrub nurse pulling and an anesthesiologist pushing. As the group came abreast Susan could see that the anesthesiologist was matter-of-factly holding the patient’s chin back while the patient retched violently. “I hear there’s almost forty inches of packed powder at Waterville Valley,” said the anesthesiologist to the scrub nurse. “I’m going Friday right after work,” returned the scrub nurse as the
pair passed by Susan toward the recovery room. The image of the tortured face of the patient so recently operated on imprinted itself in Susan’s susceptible consciousness and she shuddered involuntarily.
The group pulled up in front of room 18.
“Try to keep the chatter to a minimum,” said Bellows, looking through the window in the door. “The patient is already asleep. Too bad, I wanted you to see that. Well, no matter. There will be a lot of moving around during the draping procedure, etcetera, so stay back against the right wall. Once they get under way, move around so that you can see something. If you have questions, save them until later, OK?” Bellows looked at each student. He smiled anew when he met Susan’s gaze, then pushed open the OR door.
“Ah, Professor Bellows, welcome,” boomed a large, gowned, gloved, and sterile figure hovering in the background near some X-rays. “Professor Bellows has brought his brood of students to watch the fastest hands in the East,” he said laughing. He held up his arms in an exaggerated Hollywood surgical fashion with the hands up and bent outward as far as they would go. “I hope you have told the impressionable youths that the spectacle they are about to see is a rare treat.”
“That hulk,” said Bellows to the students while motioning toward the laughing character by the X-rays and loud enough for all in the OR to hear, “is the result of staying in the program too long. That’s Stuart Johnston, one of the three senior residents. We only have to put up with him for four more months. He had promised me he’d be civil, but I cannot be sure of that.”
“You’re just a poor sport, Bellows, because I stole this case from you,” said Johnston, still laughing. Then to his two assistants he said without laughing, “Let’s get the patient draped, you guys. What are you trying to do, make this your life’s work?”
The draping proceeded rapidly. A small piece of tubular metal arched over the top of the patient’s head and separated the anesthesiologist from the surgical area. By the time the draping was completed, only a small portion of the patient’s right upper abdomen was exposed. Johnston moved to the patient’s right side; one of the assistants went over to the left side. The scrub nurse moved over the draped Mayo stand, straining with a full complement of surgical instruments. A profusion of hemostats was lined up in a perfect array along the back of the tray. The scalpel had a new razor-sharp blade snapped into its jaws.
“Knife,” said Johnston. The scalpel slapped into his gloved right hand. With his left hand he pulled the abdominal skin away from him to provide countertraction. The medical students all moved forward silently and strained to see with a foreboding curiosity. It was like watching an execution. Their minds tried to prepare themselves for the image that was going to be imminently transmitted to their brains.
Johnston held the scalpel about two inches above the pale skin while he looked over the screen at the anesthesiologist. The anesthesiologist was slowly letting the air out of the blood pressure cuff and watching the gauge. 120/80. He looked up at Johnston and gave an imperceptible nod, tripping the poised guillotine. The scalpel dived deep into the tissues, and then with a smooth soundless slice, slid down the skin at an angle of approximately 45 degrees. The wound fell open and little jets of pulsating arterial blood sprayed the area, then ebbed and died.
Meanwhile curious phenomena occurred in George Niles’s brain. The image of the knife plunging into the skin of the patient was displayed instantly in his occipital cortex. Association fibers picked up the message and transported the information to his parietal lobe, where it was associated. The association spread so rapidly and so widely that it activated an area of his hypothalamus, causing widespread dilation of his blood vessels in his muscles. The blood literally drained from his brain to fill all the dilated vessels, causing George Niles to lose consciousness. In a dead faint he fell straight backward. His flaccid neck snapped his head against the vinyl floor with a resonant thump.
Johnston spun around in response to the sound of George’s head smashing against the floor. His surprise quickly metamorphosed into typically labile surgical anger.
“For Christ’s sake, Bellows, get these kids outa here until they can stand the sight of a few red cells.” Shaking his head, he went back to catching bleeders with his hemostats.
The circulating nurse broke a capsule under George’s nose and the acrid smell of the ammonia shocked him back to consciousness. Bellows bent down and felt along his neck and the back of his head. As soon as George was fully conscious, he sat up, somewhat confused about his whereabouts. Realizing what had happened, he felt immediately embarrassed.
Johnston meanwhile wouldn’t let the matter rest.
“Holy shit, Bellows, why didn’t you tell me these students were absolute greenhorns? I mean, what would have happened if the kid fell into my wound here?”
Bellows didn’t say anything. He helped George to his feet by degrees until he was satisfied George was really OK. Then he motioned for the group to leave OR No. 18.
Just before the OR door shut, Johnston could be heard angrily yelling at one of his junior residents, “Are you here to help me or hinder me . . . ?”
February 23
11:15 A.M.
George Niles’s pride was hurt more than anything else. He developed a rather sizable lump on the back of his head but there was no laceration. His pupils stayed equal in size and his memory was unimpaired. Consensus had it that he was going to make it. However, the episode dampened the spirits of the whole group. Bellows was nervous that the fainting would reflect on his judgment to bring the students into the OR on the first day. George Niles was concerned lest the incident foreshadowed similar responses every time he tried to watch a surgical case. The others were bothered to a greater or lesser degree simply because within a group, the actions of one individual tend to reflect the whole group’s performance. Actually Susan was not concerned with this aspect as were the others. Susan was more distressed about the sudden and unexpected response and change in attitude of Johnston and, to a lesser extent, Bellows. One minute they were jovial and friendly; the next minute they were angry, almost vengeful, simply because of an unexpected turn of events. Susan rekindled her preconceptions regarding the surgical personality. Perhaps such generalizations were appropriate.
After changing back to their street clothes, they all had a cup of coffee in the surgical lounge. It was surprisingly good coffee, thought Susan, trying to overcome the oppressive haze of cigarette smoke which
hung like Los Angeles smog from the ceiling to a level about five feet from the floor. Susan was mindless of the people in the lounge until her eyes met the stare of a pasty white-skinned man hovering in the corner near the sink. It was Walters. Susan looked away and then back again, thinking that the man was not really watching her. But he was. His beady eyes burned through the cigarette haze. Walters’s omnipresent cigarette hung by some partially dried saliva holding the extreme tip in the corner of his lips. A trail of smoke snaked upward from the ash. For some unknown reason he reminded Susan of the hunchback of Notre Dame, only without a hunchback: a ghoulish figure out of place yet obviously at home in the shadows of the Memorial surgical area. Susan tried to look away but her eyes were involuntarily drawn toward the uncomfortable stare of Walters. Susan was glad when Bellows motioned to leave and they drained their cups. The exit was near to the sink, and as the group left the room, Susan had the feeling she was walking down Walters’s line of vision. Walters coughed and the phlegm rattled. “Terrible day, eh, Miss,” said Walters as Susan passed.
Susan didn’t respond. She was glad to be rid of the staring eyes. It had added to her nascent dislike of the surgical environment of the Memorial.
The group moved en masse into the ICU. As the oversized ICU door closed, the outside world faded and disappeared. A surrealistic alien environment emerged out of the gloom as the students’ eyes adjusted to the lower level of illumination. The usual sounds like voices and footsteps were muted by the sound-absorbing baffling in the ceiling. Mechanical and electronic noises dominated, particularly the rhythmical beep of the cardiac monitors and the to-and-fro hiss of the respirators. The patients were in separate alcoves, in high beds with the side rails pulled up. There was the usual profusion of intravenous bottles and lines hanging above them, connected to impaled blood vessels by sharp needles. Some of the patients were lost in layer upon layer of mummylike bandages. A few of the patients were awake and their darting eyes betrayed their fear and the fine line that divided them from acute insanity.
Susan surveyed the room. Her eyes caught the fluorescent blips racing across the front of the oscilloscope screens. She realized how little information she could garner from the instruments in her present state of ignorance. And the I.V. bottles themselves with their complicated labels signifying the ionic content of the contained fluid. In an instant, Susan and the other students felt the sickening feeling of
incompetence; it was as if the entire first two years of medical school had meant nothing.
Feeling a modicum of safety in numbers, the five students moved even closer together and walked in unison to one of the center desks. They were following Bellows like a group of puppies.
“Mark,” called one of the ICU nurses. Her name was June Shergood. She had thick luxurious blonde hair and intelligent eyes that looked through rather thick glasses. She definitely was attractive and Susan’s keen eye could detect a certain change in Bellows’s demeanor. “Wilson has been having a few runs of PVCs, and I told Daniel that we should hang a lidocaine drip.” She walked over to the desk. “But good old Daniel couldn’t seem to make up his mind, or . . . something.” She extended an EKG tracing in front of Bellows. “Just look at these PVCs.”
Bellows looked down at the tracing.
“No, not there, you ninny,” continued Miss Shergood, “those are his usual PVCs. Here, right here.” She pointed for Bellows and then looked up at him expectantly.
“Looks like he needs a lidocaine drip,” said Bellows with a smile.
“You bet your ass,” returned Shergood. “I mixed it up so I could give about 2 mg per minute in 500 D5W. Actually it’s all hooked up and I’ll run over and start it. And when you write the order include the fact that I gave him a bolus of 50 mg when I first saw the runs of PVCs. Also maybe you should say something to Cartwright. I mean, this is about the fourth time he couldn’t make up his mind about a simple order. I don’t want any codes in here we can avoid.”
Miss Shergood bounced over to one of the patients before Bellows could respond to her comments. Deftly and with assurance she sorted out the twisted I.V. lines to determine which line came from which bottle. She started the lidocaine drip, timing the rate of the drops falling into the plastic chamber below the bottle. This rapid exchange between the nurse and Bellows did little to buoy the already nonexistent confidence of the students. The obvious competence of the nurse made them feel even less capable. It also surprised them. The directness and seeming aggressiveness of the nurse was a far cry from their rather traditional concept of the professional nurse-physician relationship under which they all still labored.
Bellows pulled out a large hospital chart from the rack and placed it on the desk. Then he sat down.
Susan noticed the name on the chart.
N. Greenly.
The students crowded around Bellows.
“One of the most important aspects of surgical care, any patient care really, is fluid balance,” said Bellows, opening the chart, “and this is a good case to prove the point.”
The door to the ICU swung open, allowing a bit of light and hospital sounds to spill into the room. With it came Daniel Cartwright, one of the interns on Beard 5. He was a small man, about five seven. His white outfit was rumpled and blood-spattered. He sported a moustache but his beard was not very thick and each hair was individually discernible from its origin to its tip. On the crown of his head he was going bald rather rapidly. Cartwright was a friendly sort and he came up to the group directly.
“Hi, Mark,” said Cartwright making a gesture of greeting with his left hand. “We finished early on the gastrectomy so I thought I’d tag along with you if I may.”
Bellows introduced Cartwright to the group and then asked him to give a capsule summary on Nancy Greenly.
“Nancy Greenly,” began Cartwright in a mechanical fashion, “twenty-three-year-old female, entered the Memorial approximately one week ago for a D&C. Past medical history entirely benign and noncontributory. Routine pre-op workup normal, including negative pregnancy test. During surgery she suffered an anesthetic complication and she has been comatose and unresponsive since that time. EEG two days ago was essentially flat. Current status is stable: weight holding; urine output good; BP, pulse, electrolytes, etcetera, all OK. There was a slight temperature elevation yesterday afternoon but breath sounds are normal. All in all, she seems to be holding her own.”