On Nicholas’s first morning at the clinic, he was called into the emergency room. A severely diabetic elderly man had consulted a shaman, a tribal medicine man, who had poured hot tar on his legs as part of the treatment. Horrible sores blistered up, and two physicians were trying to hold down his legs while a third examined the extent of the damage. Nicholas had hung back, not certain what he was needed to do, and then the second patient was brought in. Another diabetic, a sixty-year-old woman with heart disease, who had gone into cardiopulmonary arrest. One of the staff doctors had been jamming a plastic tube down the woman’s throat to manage the airway and to breathe for her. He did not look up as he shouted at Nicholas. “What the hell are you waiting for?” he said, and Nicholas stepped up to the patient and began CPR. Together they had tried to get the heains‘ get the rt moving again, forty minutes of CPR, defibrillation, and drugs, but in the end the woman died.
During the month that Nicholas spent in Winslow, he had more autonomy than he’d ever had as a student at Harvard. He was given his own patients. He wrote up his own notes and plans and ran them by the eight staff physicians. He rode with public health nurses in four-wheel-drive vehicles to find those Navajos with no true addresses, who lived off the paths of roads, in huts with doors that faced the east. “I live eight miles west of Black Rock,” they wrote on their face sheets, “just down the hill from the red tree whose trunk is cleaved in two.”
At night Nicholas would write to Paige. He mentioned the dirty hands and feet of the toddlers, the cramped huts of the reservation, the glowing eyes of an elder who knew he was going to die. More often than not, the letters came out sounding like a list of his heroic medical feats, and when this happened Nicholas burned them. He kept seeing the unwritten line that ran through the back of his mind: Thank God this isn’t the kind of doctor that I’m going to be-words never committed to paper that were still, he knew, indelible.
On his last day at the Indian Health Service, a young woman was brought in, writhing in the throes of labor. Her baby was breech. Nicholas had tried palpating the uterus, but it was clear a C-section was going to be necessary. He mentioned this to the Navajo nurse who was acting as translator, and the woman in labor shook her head, her hair spilling over the table like a sea. A Hand Trembler was called in, and Nicholas respectfully stepped back. The medicine woman put her hands over the swollen belly, singing incantations in the language of the People, massaging and circling the knotted womb. Nicholas told the story when he returned to Boston the next day, still thinking of the dark gnarled hands of the medicine woman, suspended above his patient, the red earth flurrying outside and hazing the window. “You can laugh,” he said to his fellow interns, “but that baby was born headfirst.”
“Nicholas,” Paige said, her voice thick with sleep. “Hi.”
Nicholas curled the metal cord of the pay phone around his wrist. He should not have awakened Paige, but he hadn’t spoken to her all day. Sometimes he did this, called at three or four in the morning. He knew she’d be asleep, and he could imagine her there with her hair sticking up funny on the side she’d been sleeping on, her nightgown tangled around her waist. He liked to picture the soft down comforter, sunken in spots where her body had been before she had reached to answer the phone. He liked to imagine that he was sleeping next to her, his arms crossed under her breasts and his face pressed into her neck, but this was unrealistic. They slept at opposite sides of the bed, both fitful sleepers, unwilling to be tied by someone else’s movements or smothered by someone else’s heated skin.
“Sorry I didn’t call this afternoon,” Nicholas said. “I was busy in ICU.” He did not tell Paige about the patient he’d had to code. She always wanted details, playing him for a superstar, and he wasn’t in the mood to go into it all over again.
“That’s okay,” Paige said, and then she said something muffled into the pillow.
Nicholas did not ask her to repeat herself. “Mmm,” he said. “Well, I guess I don’t have anything else to say.” When Paige did not respond, he hit the # button on the phone.
“Oh,” Paige said. “Okay.”
Nicholas scanned the hall for signs of activity. A nurse stood at the far end, dropping little red pills into cups that were lined up on a table. “I’ll see you tomorrow,” Nicholas said.
Paige rolled onto her back; Nicholas knew by the crinkling of the pillows and the fluff of her hair when it settled. “I love you,” Paige said.
Nicholas watched the nurse, counting the pills. Eighteen, nineteen, twenty. The nurse stopped, pressed her hands into the small of her back as if she was suddenly weary. “Yes,” Nicholas said.
The next morning Nicholas did prerounds at five-thirty and then began regular rounds with Fogerty and an intern. The patient Nicholas had coded yesterday was doing fine, comfortably settled in surgical ICU. By seven-thirty they were ready for their first surgery of the day, a simple bypass. As they scrubbed, Fogerty turned to Nicholas. “You did well with McLean,” he said, “considering you’d just come onto the rotation minutes before.”
Nicholas shrugged. “I did what anyone would have done,” he said. He scrubbed at invisible germs under his nails, around his wrists.
Fogerty nodded to an OR nurse and shrugged into his sterile gown. “You make decisions well, Dr. Prescott. I’d like you to act as chief surgeon today.”
Nicholas looked up but did not let the surprise he felt show in his eyes. Fogerty knew he’d been on call all night, knew he’d need a second wind to measure up. Fogerty also knew it was virtually unheard of for a third-year resident to lead a bypass operation. Nicholas nodded. “You got it,” he said.
Nicholas spoke quietly to the patient as the anesthesiologist put him under. He stood beside Fogerty as the second assistant, a resident more senior than Nicholas who was obviously angry, shaved the legs, the groin, the belly, and covered the body with Betadine solution. The patient lay motionless, stark naked, stained orange, like a sacrifice for a pagan god.
Nicholas supervised the harvest of the leg vein, watching as blood vessels were clamped off and sewn, or were cauterized, filling the operating suite with the smell of burning human tissue. He waited until the vein was settled in solution for its later use. Then, stepping up to the patient, Nicholas took a deep breath. “Scalpel,” he said, waiting for the nurse to pick the instrument off a tray. He made a clean incision in the patient’s chest and then took the saw to cut through the sternum. He held the ribs spread apart with a rib spreader, and then he exhaled slowly, watching the heart beating inside the man’s chest.
It never failed to amaze Nicholas how much power was in the human heart. It was phenomenal to watch, the dark-red muscle pumping quickly, t1em‘g quicklyurning hard and small with each contraction. Nicholas cut the pericardium and separated out the aorta and the vena cava, connected them to the bypass machine, which would oxygenate the blood for the patient once his heart was stopped by Nicholas.
The first assistant poured the cardioplegia liquid onto the heart, which stopped its beating, and Nicholas, along with everyone else in the room, turned his eyes to the bypass machine, to make sure it was doing its job. He bent closer toward the heart, snipping at the two coronary arteries that were blocked. Nicholas retrieved the leg vein, delicate, and turned it so that the valves did not hold blood back but let it through. With careful sutures he sewed the vein onto the first coronary artery before the point of blockage, and then attached the other end after the point of blockage. His hands moved with a will of their own, precise and steady, fingers blunt and strong beneath the translucent gloves. The next steps streamed through his mind, but the procedure and his role in it had become so natural to him, like breathing or batting right-handed, that Nicholas began to smile. I can do this, he thought. I can really do this on my own.