Abraham Verghese - Cutting for Stone

Popsy made Deepak Chief Resident overnight, but with the proviso that he be Chief Resident for two years. Deepak was in his last year of training when I arrived.

“So you will be done the same day I finish my internship?”

His silence made me anxious.

Slowly he shook his head.

“We got notice today of a site visit soon from the people who accredit our residency training program. If they don't like what they see, they can shut us down. We've got too few interns. And too few resident physicians at every level for the patient volume we handle. Not to mention too few faculty.”

“How did this happen?”

“Our competition is sweetening the pot. We were lucky to get you and Nestor and Rahul. We need more interns, more full-time faculty. Popsy just isn't as influential as he once was to attract good faculty. At this point, it's only Popsy s credentials and academic history that give our program accreditation. On paper, Popsy is golden. If Popsy steps down, or word gets out that he has early dementia, the house of cards falls.”

I must have looked concerned because he said, “Don't worry. You'll be able to find another slot and get credit for this year.”

“Is that what it is about—the bailiff serving you papers?”

“Oh, that's my so-called wife. Now she thinks I must be making a lot of money so she is filing in New York for spousal support. I have a lawyer who tells me that I have nothing to worry about. I owe her nothing.”

“What about you, Deepak? What will you do if this place closes?”

“I don't know, Marion. I can't go through this again. Can't keep assisting someone who is my ‘senior’ but is butchering the case and doesn't have the sense to ask me to help. Maybe I'll just keep on working here. Sister Magda says the hospital will employ me. I'll live here, just like Popsy lives here. I'll operate. The hospital doesn't care if I am board certified or not, particularly if the residency program closes. Our Lady needs a surgeon. I'll be another Popsy. Believe it or not, Popsy, till his breakdown, was a super surgeon,” Deepak said. “What's more important, he was a fine man. Truly color-blind.”

After Mr. Walters's surgery, Deepak had spread the word that Popsy was not to operate anymore at any cost.

“Is there anything we can do to keep them from shutting us down?” I asked Deepak.

“Pray,” he said.

IPRAYED, BUT IT DIDN'T HELP. With two months to go to finish my internship and for Deepak to finish his Chief Residency, our program was placed on probation. I worried about my fate. It was bad enough that we might be closed down, but it would be worse not to get credit for the year I'd put in. I felt terrible for Deepak, who had come so close to finishing his Chief Resident year. Until our appeal was heard, though, and the final order came to shut us down, there was little to do but plod on.

On a Friday evening, I was summoned to the trauma room, and I reached there just as the ambulance roared in. The crew slid out a stretcher, snapped its wheels down, then raced in with it as if it were a battering ram. The glass doors parted just in time. I thought of these things as minor miracles, everyday efficiencies that were such a contrast to what I'd known in Africa. I jogged alongside. After almost a year at Our Lady, I'd done this many times, but the adrenaline still surged.

“John Doe, MVA, barely breathing at the scene,” one of the men pushing the stretcher said. “Ran a red light, got broadsided by a van on driver's side. No seatbelt—went airborne through windshield … Then, if you can believe this, his own car, spinning around, slammed into his body. Fly ball to centerfield … Kid you not. Eyewitnesses. He landed on the pavement. No obvious neck injuries. Left ankle shattered … bruises on chest and belly.” I saw a handsome black male, clean-cut and no older than twenty.

The ambulance crew had two bags of intravenous saline going wide open. They had drawn blood, and now they handed over the red-, blue-, and lavender-topped tubes to the lab technician, who would begin typing and cross matching for blood before we'd even cut off the patient's clothes.

“There's more to this,” the ambulance driver said. “Reason he ran the red light is because he was in a gunfight with gangbangers. One of them got shot in the head. An ambulance is on its way with that guy. Don't worry … it ain't no emergency. They had to scoop parts of his brain off the sidewalk—kindergarten through fifth grade from the looks of it. This guy,” he said, pointing to our patient, “did the shooting.”

Our patient's skull was intact, but he was unconscious. The part buzzed into his short hair was as straight as if it had been applied with a ruler. It was one of the strange things one noticed at such times. His pupils constricted briskly to the light I shone at them, a crude but reassuring sign that his brain was all right. His pulse was thready and racing under my fingers. The monitor read one hundred sixty beats a minute.

A nurse called out the pressure. “Eighty over nothing.” A few seconds later she said, “Fifty over zero.”

Fluids were pouring in, blood was on its way. There was a bruise over the lower right ribs. His belly was tense and it seemed to be swelling under my eyes.

“No pressure,” the nurse announced just as the X-ray technician arrived with the portable machine.

“No time for this. He's exsanguinating,” I said. “Let's take him to the operating room. It's his only chance.”

Nobody moved.

“Now!” I said, giving the stretcher a push. “Call my backup, let them know.”

In the operating room, I scrubbed for just thirty seconds, while Dr. Ronaldo, the anesthetist, adjusted the tracheal tube. Ronaldo looked at me and shook his head.

I pulled on my gloves while looking at what the scrub nurse had laid out.

“Forget sponges. Let's get lap packs. Open them out. We won't have time to unfold them. There is going to be so much blood. We'll need big basins to hold the clots.”

The patient's belly was more tense than it had been downstairs.

Ronaldo, peering crocodilelike above his mask, shrugged when I looked at him for the signal to start.

“Get ready,” I said to Ronaldo, “ ‘cause when I open, the pressure is going to bottom out.”

“What pressure?” Ronaldo said. “No pressure.”

For now, the blood expanding the belly was serving as a compress, tamping off the bleeding vessel wherever it was. But the moment I opened the belly, the geyser would open again. I layered pads all around. I poured Betadine over the skin, swabbed it off, said a prayer, and cut.

Blood welled out, spilled over the edge of the wound like a storm surge. Despite all the pads, despite my suction hose sucking greedily, the blood lapped over the drapes, onto the table, and splashed to the floor. I felt it soak through my gown, felt it on my thighs, in my socks, my feet squishing in my shoes.

“More packs!” Id tried to warn the nurses, but we were still unprepared for the torrent.

I reached in with my hand, displacing a second wave of blood as I grabbed the small bowel. With two hands now, I pulled loops out, fed them onto a towel by the side of the incision. In seconds I had effectively disemboweled the patient.

Deepak appeared across from me, scrubbed and ready. I clasped my hands together, stepped back to cross to the other side of the table, but he shook his head.

“Stay there,” he said. He grabbed a retractor and pulled so I could see under the diaphragm.

I stuffed the lap packs all around the liver. Then I did the same on the left side, in the vicinity of the spleen. With cupped fingers, I scooped out the big clots that remained in the abdominal cavity. I jammed more packs all over the abdomen and into the pelvis, until everything was wedged tight. No blood vessel was pumping that I could see.