With a definite sense of confusion, Mitt tried to grapple with what he thought he’d seen, namely the forceps tumbling off the instrument tray on their own, which was impossible because they were bound by the same laws of gravity as everything else in the universe. He shook his head, realizing he must have conjured up the event out of a combination of his boredom and anxieties. There was no way he’d seen what he thought he’d seen, no way at all. With that decided, Mitt went back to just trying to get through the experience, keeping tension on the retractor despite his complaining muscles and letting his eyes and mind wander.
“Okay!” Dr. Washington said sometime later in an encouraging tone, pulling Mitt back to reality. “It’s done! Finally, the proximal end of the graft is sutured in place. That was not easy, but it’s done. Now let’s move on to suture the distal end, and once we’ve done that, we’re out of here.”
“Great job!” Dr. Rodriguez said as he took a step to the left, moving out from in front of Mitt. Suddenly Mitt wasn’t staring at Dr. Rodriguez’s back but could see Dr. Washington, and more important, by leaning forward, he had a view into the wound. By bending a bit to the left, he could even see the sutured end of the graft up under the diaphragm.
Mitt felt Dr. Rodriguez take the retractor from him, which the fourth-year resident repositioned to expose the distal end of the transected aorta, and then, without a word, reattached Mitt’s hand to the instrument’s handle. For a moment, Mitt felt as if he were being treated as an insensate extension of the retractor. But then he silently criticized himself for faultfinding, because, after all, he was being afforded the opportunity to help save a person’s life.
“The cut end of the aorta also looks a bit questionable to me,” Dr. Rodriguez said. “What’s your take, Dr. Washington?”
“I see what you mean,” Dr. Washington said. He asked for a pair of forceps and scissors and snipped off a tiny piece of the vessel. “Let’s have Pathology take a quick gander at this section as well. We might have to remove more of the aorta. Let’s hope it isn’t defective all the way down to the renal arteries. That would change this into one hell of a marathon procedure.”
This time, there was no problem with the exchange of the biopsy between the surgeon and the scrub nurse, and within minutes the circulating nurse disappeared from the OR to take it to Pathology.
While they waited for the results, Dr. Washington gave Mitt a short tutorial on the operative treatment of abdominal aneurysms, belatedly stimulating Mitt’s interest in the procedure. He even talked about Dr. Valentine Mott, a celebrated Bellevue surgeon from the early nineteenth century who had been willing to operate on such abdominal aneurysms before anesthesia and antisepsis.
“The man was a Bellevue phenomenon,” Dr. Washington gushed. “The speed with which he had to work because of the lack of anesthesia was truly unbelievable.” With that comment, Dr. Washington glanced over the anesthesia screen to acknowledge the role the anesthesiologist played. The anesthesiologist nodded in return, happy to accept the recognition.
Dr. Valentine Mott was a historical figure whom Mitt knew something about, as Mitt’s ancestor Dr. Homer Fuller had been a contemporary of Mott’s at Bellevue Hospital. Mitt often thought about how technically difficult and stressful it must have been being a surgeon back then without anesthesia, considering the sheer pain the patients had to endure. In those days operative speed was crucial. He’d read that Dr. Homer Fuller had done an amputation at mid-thigh in nine seconds. On top of the speed requirement was the burden of postoperative infections. In those days as many as half of all patients operated on died of sepsis.
“The aortic wall is definitely abnormal and probably won’t hold a suture,” the circulating nurse announced the moment she pushed back into the OR. “A formal report will be forthcoming, but the pathologist wanted you to know ASAP.”
“Oh, shit,” Dr. Washington voiced, looking back into the wound with a shake of his head. “As I said, this could turn out to be one hell of a long case.”
Chapter 6
Monday, July 1, 5:20 p.m.
Mitt raised his eyes to look at the wall clock and marveled at the position of the hour hand. In many ways he couldn’t believe he was still on the same case. It had been close to eight hours since he’d entered OR #12. Even more impressive, Dr. Washington, Dr. Rodriguez, and Dr. Wu had been working for almost ten hours.
As a medical student Mitt had heard of exceptionally long surgical procedures, but he’d been led to believe they involved unusual cases like face transplants or the separation of conjoined twins that require the participation of multiple surgical specialties and not more routine conditions like an abdominal aneurysm. Never in his wildest imagination could he have guessed he’d be caught up in such a rite of passage on his very first case as a surgical resident. Was such an unusual, luck-of-the-draw circumstance a good omen or a bad one as far as his residency was concerned? He had no idea, and there was no way to guess. All he knew was that he was currently bored silly.
On the positive side, since the conclusion of the difficult suturing of the proximal section of the graft when his view of the operative field had been completely blocked, he’d been able to see — and thanks to Dr. Washington’s explanations to understand — what was transpiring even though he wasn’t contributing much. Consequently, he knew exactly why the case was dragging on for so long. It was all because the patient’s aorta, at least the abdominal portion, had extensive developmental abnormalities, causing its wall to be considerably thin and friable. It was this problem that explained not only the origin of the aneurysm but also why Dr. Washington had had to remove more and more of the vessel to find a portion strong enough to hold sutures. He was doing this by taking progressive biopsies and sending them off to Clinical Pathology. Unfortunately, as this process continued, it involved sacrificing sections of the aorta with branches that provided arterial blood to various abdominal organs including the kidneys. Each of these vessels had to be separately connected to the graft, requiring a ton more suturing and lots more time.
But the technical difficulty of the surgery wasn’t the only reason the case was taking so long. The tension between the surgeon and the scrub nurse had continued, underlining for Mitt how important it was that their interaction be smooth. Not long after the forceps incident, there was an awkward handoff of a needle holder. At the time, Dr. Washington reached for it without taking his eyes from the site where he intended to place the next suture, but then moved his hand. As a result, instead of the instrument being slapped into his waiting palm, it hit up against his thumb and fell onto the drapes.
Again, from Mitt’s vantage point, there was blame on both sides. Dr. Washington’s hand had definitely moved at the last second, but it was also true that the scrub nurse had let go of the instrument too soon in her eagerness to pick up the empty needle holder the surgeon had just dropped onto the drapes. It was like a miscue between track-and-field sprinters exchanging a baton in a relay race.
Since there was already a degree of acrimony in the air from the previous miscues and since both the surgeon and the scrub nurse were strong-willed and highly confident in their professional abilities, neither was about to accept responsibility. The result was a harangue from the surgeon followed by one from the scrub nurse followed by a pregnant pause as if a time bomb was about to go off. It took the anesthesiologist to speak up and remind everyone that, in his words, “time’s a-wasting.” “Come on, guys,” he added. “Call a truce! We need to finish up this case.”