Paris Twilight (38 page)

No one but God noticed, generally. The crew was now quite busy. Odile was officially a thing. She'd been unrobed and slathered orange-yellow with antiseptic, her gentle belly jiggly as tired aspic as they swabbed her, the swabbing as unceremonious as painting an apartment wall or basting a fowl, her legs spread wide. The circulator nurse was bent between her legs, parting away from the brown folds of her labia the stray thin wisps of her pubic beard as he fed a catheter into her urethra.

The bustle in the room, the general obliviousness to the profundity of this human frailness, exacerbated the impression I always had, whenever I thought to notice it, that the patient was an invisible angel. She might have descended out of her celestial plane just as unnoticed to levitate anywhere—over a city sidewalk or midfield in a playground—but she had chosen to descend to the center of OR 5. The impression was exact. We in our scrubs were proudly at our knitting, busy people busy with our worldliest routines, while Odile, divested of all will (and all clothes) and tossed so thoroughly out of conceivable existence, reposed in a submission so complete it was tantamount to grace. I gathered two short pieces of transparent tape and moved to seal her eyelids to her cheeks, to keep her eyes protectively closed, as is customary, and then I paused—and then put the tape on anyway.

Willem had come in and was leaning against the tile wall completing his paperwork. The scrub nurse was counting her array of calibrated gold and silver clamps, and the perfusionist had pulled up a stool behind the heart-lung bypass machine, a contraption the size of an upright piano made of stainless steel, a carillon of big and little bottles and long and longer tubes. When Odile drifted off, I took her to the final level, administered the paralytic, and prepared to put the line in.

I swabbed her neck, and inserted the hypodermic. I could feel it enter the vessel right away, and I pulled back on the syringe and checked the color of the blood. It was dark, not arterial crimson, thankfully—there was always a tiny ping of relief; you didn't want to get that one wrong—and I said to myself, “Jugular,” and fed in the guide wire. I made a nick in the skin around the wire to accommodate the large hollow dilator sheath. I floated the catheter over the guide wire, slowly, pushing an increment with each throb of her pulse, down the living tube. The vein coursed beneath the skin of her neck before submarining into her chest. I advanced the catheter to the vena cava, just above the heart, removed the guide wire, verified the blood flow, and then sutured the catheter in place. “Line's in,” I announced when I'd gotten it arranged the way I wanted it.

I inspected Odile's pharynx with a laryngoscope, and edged a breathing tube down her throat and between her vocal cords, lungward. She accepted it easily, the dear. Some throats are so resistant (some in fact almost impossible). I attached the bag and squeezed the pleated fabric and released, and squeezed it again, and watched the rise and collapse of her shiny chest.

“We're breathing,” I told the room.

The yellow corpus was gone now. The circulator nurse had packed Odile carefully in prodigious layers of Sanidrape, so that only a rectangle of her chest was visible through the sky of blue shrouds, and her face and neck, and I stretched the ether shield across her neck, the blood-brain barrier between Willem's world and mine: his rectangle of thorax, my cradled head. Soon Odile would be an inert mound of cornflower blue trailing gussets of reddest red through seven-foot-long tubes into a contraption by her feet.

Willem said loudly, “Hard stop.”

Activity ceased, even the flurry of fingers, even the shuffling of clogs, and there was only the slow electronic
beep, beep
of heartbeat on the monitor. The circulator nurse reached for his checklist.

“Patient name?” Willem said.

“Sahran, Odile,” the nurse said.

“Procedure?”

“Transplant, simple.”

“Organ?”

“Heart.”

“Surgical site?”

The assisting surgeon said, “Not marked.”

“Allergies?”

“None,” I said.

“Any clinical or nonroutine issues?” It wasn't for me to answer, but no one else spoke.

“Cerebral palsy,” I said. “From birth. Lower-limb paralysis, blindness. Past surgeries for associated complications, abdominal and orthopedic.”

“Have you given any pre-op antibiotics?” he asked me.

“No.”

He looked up and around the huddle.

“Does anyone have anything to disclose?”

A brief silence, then six consecutive individual noes, followed by another, final.

“No,” Willem declared.

The circulator nurse tied the strings of Willem's mask behind his head, and as I watched him nudge his goggles back onto his nose my affection overwhelmed me. It had been a long time since we'd worked together, and I was reminded why I liked to, because he was so very thorough. Not every attending surgeon does a hard-stop time-out, but Willem always did, assuring we had set out to commit the right acts on the right patient. Everything up to now was reversible. What was to come was not. With a scalpel, he sliced a shallow, straight incision from clavicle to diaphragm down the center of Odile's chest, parting her skin to expose the fascia beneath.

“Bovie,” Willem said, and the scrub nurse handed him the hot-tipped wand of the cauterizing knife. Out in the night air—the air of a couple nights past—the conversation had lasted nearly half an hour, and the impatient crowd had set up its clamor again. For a while, the pair on the steps had occupied the center of an excruciating concentrated quiet. I was glad when the resuming roar gave them back their privacy. I stood immobile in the crush and tumble, feeling, except for Drôlet's protective, restraining arm around my waist, untouched and alone.

Across the avenue the two of them sat, tiny adjacent figures in their bubble of back-and-forth. I could see the talk ebb at times to nothing, to sulk, and then come animating all the way back to argument. I tried to conjure the words at play, the moments of risk and reassurance, whether the end would spell life or disaster for both. And ahead of the crowd's noticing, I noticed. And my heart whistled long, so long, before the crowd's great deafening whistle marked the moment when she moved her arm and reached out to hand Emil the lamp, and before he reached to set it aside on the stair and rolled back to hug her with her head in his hand and pulled her temple against his chest, and before the centurions turned from guards to jailers and rushed to bury them in a mountainous tackle, I saw him draw down the wicked wick and, between tongue-moistened fingers, pinch the heat out of the flame, and the little puff of ash-smoke ascended like an offering on the air. Willem lay the hot point of the Bovie knife to the top of the incision in Odile's chest, and drew down the first long line. The yellow flesh cringed from the livid scorch to reveal an arroyo of magenta and honey, and the white puff rose, and with it the atrocious aroma of Odile burnt to bacon.

B
Y THE TIME I SENSED
trouble, she was split full open, her rib cage pulled akimbo by the windlass clamped into her sternum, her pericardium unzipped and her heart exposed. For a girl who'd been on the dance floor several nights ago, she sure did need a new heart. Oh, it beat like a bean, dancing away merrily in there, bumping with insurrection like it would leap out onto the table, but you could see right away what the trouble was. It was big. It was congested and far too large and its bump was gimp. It didn't have the nice rolling ventricular gallop that marks the contractions of a healthy beating heart. Some of the muscle of the wall or septum had probably died to deadweight. It would pull the rest down eventually. Willem snipped into the aorta above this antic creature and sewed in the cannula for the bypass machine, banging on the tube to get the air out, and after I'd got the anticoagulant started and had announced, “Heparin is in,” the plastic hoses flushed table-length with that indescribable, electric bruise-bright crimson of heart blood, and the perfusionist said to the room, “We're on the pump.”

The room temperature was plummeting by then, toward the high 50s Fahrenheit that would slow Odile's metabolism and keep the iced replacement heart from warming up and beginning its rot before we could get it into her. The climate would convince the rest of us we were descending into the crypt, and soon I would reach for a blanket to shawl my shoulders, in ecstasy. I could feel myself back in the current of surgery's lovely, seductive sway, reentering the altered state it had always allowed me.

Patients after an operation notice the constrained, private look on the surgeon's face and assume he's being stoic about all the gore and corruption he's been made to witness, and they feel a bit chagrined about putting him through such horror. They want to say that they're better than this, that their best side's more human than their insides, but they're wrong. What the surgeon can't confess is that he's already witnessed them at their most magnificent, seen a side of them they'll never have the privilege of knowing, so brilliant and extraordinary, so exceptional to their dreary daily exterior that to admit the preference in its full blunt force would trouble people, would seem to revel in a ghoulish perversion of blood-love. For blood-love it is, an awe for the whole wet, mad, divine, ingenious jalopy, and even its genius afflictions, because the tumor and the lesion also attest to miracle, are full of the mystery of striving.

And the colors! To delve beneath the skin is to part the lapping flannel of the grim Atlantic and dive into a South Sea paradise, its coral reefs and tropical grottoes inhabited by every outrageous iridescence. Organs are as day-shy as deep-sea creatures; they oxidize to dun in the open air. The heart that appears a rump-roast russet when hauled out of the chest is a carny of neon inside of it. Its atria are aubergine and violet, and the red-veined fat swaddling its ventricles a synthetic, delicate, cautionary orange, the whole of it moody and mercurial, spangled as a butterfly and glistening like a poisonous frog.

Willem and his assistant stood face to face over their exquisite excavation, cutting and cauterizing and tying off. I was surprised at the rapidity of their work. Usually, a surgeon as cautious as Willem will want to have the replacement heart in hand before cutting the old one out, on the odd chance the courier has a flat on the freeway or the chartered jet hits a fog bank. But here they were, already lifting out of Odile's chest her crippled, poisonous, butterfly heart and setting it aside. The core of her gaped like a shoebox.

Odile, who had relinquished control of her lungs, now emerged into the abeyance, a category of existence unknown and unknowable; she was living but unequipped for life, her circulation waveless, her respiration breathless, her diaphragm stilled, her heart discarded, her systems supplanted by motors and regulated by chemicals, she was demi-organic and fully unviable, as incapable as a carcass. She was a thing of the future, alive without a pulse. She was a cadaver with a brain, her brain sustained by pumps and pistons over which her brain had no control, for we did. Wherever was the panel for the hospital's circuit breakers, there was a switch inside it bearing her life's label; throw it and she'd wink out like a light bulb, and what must her brain think of that? (In case of power outage, the heart-lung machine had a backup, a hand crank like a hurdy-gurdy, which fact had never offered me much comfort. It was my job to turn it.) The nurse opened the insulated cooler (a courier had just stepped in to drop it off, like clockwork) and Willem plucked the replacement organ from its bath of freezing saline.

For a while, I was swept along in the sway of all this wonder, drawn down the irresistible conveyor through the melodrama of Odile's inner workings, and I was happy with that, indescribably. As Willem kneaded the replacement heart to force the air and saline out, and then set it not delicately into its new apartment, and flopped it over face-up and edged it into position, I was sincerely glad to be working with him again. I relished him as a surgery partner for reasons that went beyond his rigor, I admit. Whatever our recent disagreements, we were still the oldest of teammates, he and I, our routines and movements shaped to each other's according to the decades and thanks to the experience of acquiring our hand trades side by side, all those many years ago. If he'd called for a Chrysler, I (alone here today) would understand what he meant—the clamp that old daft Dr. Barber had forgotten the name of that time, lamenting to the nurse absurdly that he wouldn't know it from the Chrysler Building. And if Willem demanded, “Madison,” I'd sluice the unattached organ with a dose of cold-preservation fluid (one variety of fluid is named University of Wisconsin solution). A dozen like that, a score, a gross and bushel of such. Every stable operating team coins its own language, and he and I had ours, and our own routines too, and so I knew what Willem meant when he said (to the assistant's visible surprise), “Miss Anselm, if you please?” and I slipped around the ether shield, and the circulator nurse got me elaborately antiseptic and scrubbed me in with new gloves and I joined the scrum tableside, standing next to the surprised assistant, ready for my cameo.

The particular occasion was the suturing in of the third of the four great vessels (in the order in which Willem liked to work), the inferior vena cava. It's a tricky one to stitch. Well, they're all tricky—the rubbery aorta; the flimsy, floppy pulmonary—but this one's location makes it harder to reach, and its inconsistent size makes it easy to pull or pucker. Willem had developed his own best method for reaching it, which worked reliably to relieve all strain on the suture site but benefited from an extra set of hands to prop the heart in position, and over the years and especially in private hospitals where our teams weren't augmented by fellows, those hands had often been mine. “Miss Anselm, if you please?” he said (and this its own bit of homebrew, from the first time I, a resident then myself, had been invited to dig into cardiac doings, by starchy old Dr. Oldenmeyer), and I glowed in the acknowledgment of our long association, and stepped around and got scrubbed in and as soon as Willem keyed me with a nod, I reached through the clamp into Odile's chest and cradled her luscious new bauble in my fingers, lifting it exactly the degree and angle that I knew Willem wished (he must be glad to be working with me again too!) so he and his assistant could perform their magic with arc needle and ligature.