Doing Harm (9 page)

“Of death,” he replies matter-of-factly. “I’m not afraid of death. I figure it’s like Socrates said: Death is a blessing no matter what happens after you die.”

He scoots his torso around, wincing and holding his belly with both hands. “You know what I mean, right, Steve? About what Socrates said?”

I know what Socrates said. I’ve read
The Apology.
I’m just a little surprised to learn that Mr. Bernard knows what Socrates said. I open my mouth, then close it, unsure of how to respond.

“What, with all that school you doctors have to go through and all, you never bothered to learn about Socrates and what he had to say about death?”

“I know what he said,” I answer, with just a hint of indignation.

He grins at me playfully. “I’m sure you do. A well-educated doctor like yourself. And don’t go looking at me like that, Steve.”

“Like what?”

“Like with that ‘how in the hell would a dumb-ass-working-stiff-high-school-dropout-like-this-jerk-know-anything-about-Socrates look on your face. Plain as day. Jesus, Steve. Don’t ever try to play poker. You’ll get your freakin’ ass kicked. Anyways, so the way I figure, it’s like this: Death is a win-win situation. Either it’s paradise or sleep. So there’s nothing to be afraid of. I’ve treated people good, and I believe in God, so if there’s an afterlife, I’ll go to paradise or Heaven or whatever, and like Socrates said, I’ll hang out and see cool people who died before me. Like Jerry Garcia. Man, I’d love to hang with Jerry.”

He winks. “But, if there’s no life after death … well then, the way I figure it, I’ll be in the deepest, most peaceful sleep ever, and won’t know any better anyway. That isn’t such a bad deal, either.” He looks down, grimaces, and pats his swollen belly. “Sure as hell would beat the crap out of this.” His gaze wanders back to the window. “I just want to see them alligators first,” he says quietly. “Just as soon as I get my ass out of this hospital and back into the world.”

“We’ll get you out there just as soon as we can.”

“Yeah. Yeah, I know you will.” He suddenly seems very tired. “How many kids you got again, Steve?”

“Two.”

“How old are they?”

“One’s five, the other’s ten months. Two girls.”

“Daughters. Daddy’s girls. Very nice. So explain it to me again, Steve: What are you doing here talking to a chump like me, and you’ve got those two rug rats waiting for you, along with your pretty young wife, at home?”

“I … had some things to do. To finish up. I, uh, have this weekend off.”

“Right. Some things to do. Always things to do.” He reaches out his hand, lays it on my arm, and leans toward me. The movement has an underlying urgency to it, and I’m startled to see that his eyes are wet. “Remember, Steve: The moment we’re born, we start dying. We spend our lives dying. Some of us just get there sooner. You never know when you might hop off the local and end up on the express to death. Think about it.”

I pat his outstretched hand, the one lying gently on my arm, and tell him not to worry, that he’s going to make it, that we’re going to get him out of the hospital soon, and that there’s a good chance we cured his cancer.

He shakes his head wearily, like a teacher with a slow student who just doesn’t get it, and gazes into my face sadly for several moments before taking his hand off my arm, leaning back in his chair, and focusing his attention back to the cityscape.

“I think I’m done talking to you now, Steve,” he says quietly.

As I’m leaving, I stop at the door and study his determined, craggy profile.

He looks strong. Indestructible, even, despite his grotesquely swollen belly, which pokes out from the folds of his thin hospital gown, and the thick plastic IV lines that tunnel into the skin of his arms and dive underneath his clavicle bone, tethering him to the metal IV pole standing next to his chair like air hoses attached to a deep-sea diver.

Those IV lines might as well be chains securing him to the chair, because he’s trapped here in the hospital, just as surely as if he were in jail.

All because of me.

I shut the door noiselessly behind me.

It’s the last time I ever see Mr. Bernard alive.

CHAPTER 5

Monday, July 27

I’m back from my weekend off, digging with flourish into a plate of steaming, syrup-laden pancakes, having successfully purged my mind of both Mr. Bernard and my guilt during a trip to the Franklin Park Zoo with my family. Sitting across from Luis and GG in the cafeteria, recharged with precious sleep and downtime, I’m refreshed and totally psyched up, ready to start off a new week by hearing that Mr. Bernard has turned the corner. But then Luis tells me that Mr. Bernard’s belly is still blown up to the size of a watermelon and that there are no signs that his intestines are starting to work yet. GG, sitting next to him, nods in agreement. My good mood abruptly turns foul, and my temper flares.

Goddammit,
I fume to myself.
Why didn’t this problem get fixed over the weekend? Do I need to take care of everything myself?

“The other problem is that he’s seriously hypokalemic,” Luis continues. “And we’re having a hard time keeping up with his repletion.” GG nods again.

Shit. It’s always something.

“Why is his blood potassium level so low?” I growl.

“I’m not sure, but he seems to be losing a lot of K in his urine.” Luis uses the resident slang term for potassium—the letter
K
—which sounds pretty cool, even though its origin is anything but: K is the symbol for potassium in the periodic table of the elements. Talk about geek chic. “I’m thinking that he’s peeing out K right now because of his renal failure. I think he’s starting to diurese.”

“Okay, well, just add some potassium to his TPN bag.”

“His kidneys still aren’t working that well,” he responds coolly. “His creatinine today is”—he scans the computer printout lying on the table next to his food tray—“3.5. His GFR’s still less than 20. He’s getting better, but slowly. With his renal function in flux, there’s a decent chance that, with a constant potassium infusion from his TPN, he’ll get hyperkalemic.”

Hyperkalemic.
That means too much potassium in the blood. Luis is afraid that Mr. Bernard’s weakened kidneys won’t be able to process and filter the potassium that we give him and that it will begin to accumulate in his blood. It’s a valid concern. Too much potassium in the blood can cause serious heart problems and even death.

But I’m skeptical. And thoroughly annoyed. I think Mr. Bernard’s kidneys, which have been getting better, are up to the task.

Stubborn,
Sally’s voice whispers in my brain. I shove it aside.

“I doubt it,” I counter. “If he’s really losing that much K in his urine. Just go easy on the amount of K you put in the TPN bag. And keep checking levels. I’d much rather give him a steady amount of K and keep his blood levels stable rather than responding to low levels ad hoc. It makes us look bad. Like we don’t know what we’re doing.”

“But…”

“Just fix it, Luis,” I cut in angrily. I’ve no patience this morning for debating with my junior resident. Particularly in front of GG.

Luis’s eyes narrow, and the corner of his mouth twitches. It’s the first time I’ve seen him show any emotion and, for a beat, I think he’s going to challenge me. But then he says, “Okay. Fine. I’ll put some K in the TPN bag. But just a little. I really don’t think this is a good idea, Steve.”

“I really don’t care what you think, Luis. Just fucking fix it already. Please. This patient should have been home last week. It’s making us look bad.” And I can’t afford to look bad. Not if I want that professorship.

Besides—he needs to go to an alligator farm with his lady friend.

We run through the rest of the patients on Luis’s list. There are no other major issues. I polish off my cup of coffee and head up to the OR. Sullen and bored, worried about Mr. Bernard, and pissed that we haven’t been able to fix him yet, I participate without any real enthusiasm in the first two surgeries of the day, which are both dull.

But the third operation, scheduled after lunch, is cool, and my outlook brightens in anticipation as the start time approaches. It’s the case Larry told me about last week: an adrenal gland tumor. The patient is a woman who needs to have her right adrenal gland taken out. Although the tumor is not malignant, it’s been secreting a hormone into her bloodstream that has increased her blood pressure, made her retain water, and caused her to have severe headaches. The hormone is called aldosterone, so the tumor is called an aldosteronoma. Aldosteronomas are very rare and very interesting. Cutting them out of people is surgery at its purest and best: All we have to do is take out her adrenal gland, and the tumor with it, and she’s completely cured. Clean, simple, and to the point.

I find the patient, Mrs. Samuelson, in the pre-op area, surrounded by her family. Friendly and effusive, she frets about how young, pale, and thin I look. She’s chubby, with freshly scrubbed skin and thick gray hair that she wears in a long braid. The braid makes her look much younger. Her laugh is quick and easy and reminds me of wind chimes twisting in a light breeze.

She’s from a small farming town. She’s lived there all of her life, venturing out now only because she has to for this operation. It’s easy to picture her in a busy kitchen, surrounded by her family, just as they surround her here in the pre-op area. Her three daughters look and sound exactly like her. They fuss and fret nervously, smoothing out the sheets of her gurney and adjusting her pillows.

Standing two paces from the gurney, looking thoroughly uncomfortable, is her husband. He has rough, callused palms, a pack of Marlboros tucked in the front pocket of his flannel shirt, stoic features, and not much to say. Standing next to him are two equally stoic sons-in-law, each with their own callused palms, flannel shirts, and packs of Marlboros. They have even less to say. The third son-in-law, I’m told, is out in the waiting room with the patient’s new grandson, no doubt similarly dressed and stocked with Marlboros.

While she’s being readied by the OR staff, there’s a little bit of a fuss when Mrs. Samuelson refuses to remove her wedding band—it’s OR policy for patients to remove all jewelry. But she finally relents, twisting it off her finger and handing it gingerly and, with great reluctance, to her husband.

After I’m done meeting the family, I walk over to the OR to check out our room. I like to do that before every operation, like a pilot inspecting the outside of a plane before takeoff, or a driver kicking the tires of a car. The scrub nurse is there, laying out instruments for the case. So is Larry, who’s sitting on a stool and typing on a laptop perched on his knees, bristling with manic energy.

“Hey, Slick, what up?” He grins, puts his laptop aside, jumps up, and greets me with a fist bump.

“You ready to operate today, or what, Slick?”

“Always, Larry, always.”

“Strong. Let’s look at her scan.”

Mrs. Samuelson’s CT scan is projected on a large hi-def screen in a corner. Larry and I study it together. The right adrenal gland, the site of Mrs. Samuelson’s tumor, sits on top of the right kidney, underneath the liver, and next to a big vein called the inferior vena cava, which we call the IVC for short. The IVC is the largest vein in the human body and looks like a bright white circle on the CT scan. The tumor is an ugly, misshapen sphere that pushes up against and slightly deforms the IVC.

“Looks like the tumor’s lying a little medial,” I say. “Right up against the IVC. Tiger country, huh?”

“Yes. Yes, it is.” Larry rubs his chin, lost in thought, like a general surveying a field map before a battle, composing his plan of attack. He stands perfectly still. The manic vibe dissipates, and he suddenly looks and sounds very serious, every bit the Professor of Surgery. I’ve seen him do this before when he’s worried about a patient, or—as with this case—planning out a particularly challenging operation.

“It looks pretty well circumscribed, so hopefully we’ll be able to peel it away from both the IVC and the liver. But I agree: That medial dissection might end up being a bitch. It’s really tough to see exactly where the right adrenal vein is—here, maybe?” He taps the screen with his finger. Identifying the adrenal vein, and preventing it from bleeding, will be an important part of the operation. “I’m not sure. We’ll find out once we’re in there.”

“Do you think we’ll have to convert to open?” I ask. I’m wondering if we’ll have to make a big incision in Mrs. Samuelson in order to finish the operation.

“No, I don’t think so. I think we can stay laparoscopic.”

He glances furtively over his shoulder at the female nurse unpacking surgical instruments on the other side of the room, then leans toward me, and whispers, “Converting from laparoscopic to open is for pussies who don’t know how to operate laparoscopically. You’re not a pussy, are you, Slick?”

I chuckle. “Not the last time I checked, Larry.”

“Good,” he booms. The mania has returned. “That’s what I like to hear. I’m glad you’re going to be assisting me today, Slick. I need your skills. I hope you came ready to play.” He claps my shoulder, hard.

“Larry, I always come ready to play.” I try my best to sound manly and not wince from the sharp pain now shooting up my shoulder.

The anesthesiology resident, a petite redhead named Susan, brings Mrs. Samuelson into the room with the anesthesia attending. They put Mrs. Samuelson to sleep, then deftly slip a breathing tube into her throat and hook it up to the ventilator that will breathe for her during the operation.

Now it’s our turn. Larry and I gently lift Mrs. Samuelson onto her left side and secure her into position with padded foam straps. Once Larry and I are scrubbed and the sterile field is set up, we stick a needle through the skin of her belly button and start inflating her abdomen like a balloon. Literally—a machine pumps carbon dioxide through the needle and into her abdomen. The gas fills the enclosed space that lies between her abdominal organs and overlying muscles. Her plump belly quickly swells to several times its normal size, separating her abdominal wall from the internal organs lying underneath. We then make three small incisions with the scalpel across her abdomen, through which we insert a fiber-optic video camera and several thin surgical instruments.