Abraham Verghese - Cutting for Stone

Hema's brusque “Hello” told him she was scowling. “It's me,” he said. “Do you know who I have here tonight?” He told her the story. She interrupted before he could finish: “Why are you telling me this?”

“Hema, did you hear what I just said? We have to operate. It's our duty.”

She wasn't impressed.

He added, “They're desperate. They have nowhere else to go. They have guns.”

“If they are so desperate, they can open the belly themselves. I am an obstetrician-gynecologist. Tell them I just had twins and I'm in no condition to operate.”

“Hema!” He was so mad that words would not come out. At least in the business of patient care, she was supposed to be on his side.

“Are you minimizing what I have on my hands?” she said. “What I've gone through just yesterday? You weren't there, Ghosh. So now these children's every breath is my responsibility.”

“Hema, I'm not saying …”

“ You operate, man. You've assisted him with volvulus, haven't you? I've never operated on volvulus.” By “him” she meant Stone.

The silence was punctuated only by the sound of her breathing. Does she not care if I get shot? Why take this attitude with me? As if I'm the enemy. As if I caused the disaster she walked into when she returned. Did I invite the Colonel here?

“What if I have to resect and anastomose large bowel, Hema? Or do a colostomy? …”

“I'm postpartum. Indisposed. Out of station. Not here today!”

“Hema, we have an obligation, to the patient … the Hippocratic oath—”

She laughed, a bitter, cutting sound. “The Hippocratic oath is if you are sitting in London and drinking tea. No such oaths here in the jungle. I know my obligations. The patient is lucky to have you, that's all I can say. It's better than nothing.” She hung up.

GHOSH WAS an internal medicine specialist through and through. Heart failure, pneumonia, bizarre neurological illness, strange fevers, rashes, unexplained symptoms—those were his métier. He could diagnose common surgical conditions, but he wasn't trained to fix them in the operating theater.

In Missing's better days, whenever Ghosh popped his head into the theater, Stone would have him scrub and assist. It allowed Sister Mary Joseph Praise to relax, and for Ghosh, being the first assistant to Stone was a fun change from his routine. Ghosh's presence transformed the cathedral hush of Theater 3 to a carnival racket, and somehow Stone didn't seem to mind. Ghosh asked questions left and right, cajoling Stone into talking, instructing, even reminiscing. At night, Ghosh sometimes assisted Hema when she did an emergency C-section. Rarely, Hema sent for him when she performed an extensive resection for an ovarian or uterine cancer.

But now he found himself alone, standing in Stone's place, on the patient's right, scalpel in hand. It was a spot he hadn't occupied for many years. The last time he stood on the right was during his internship when, as a reward for good service, they let him operate on a hydrocele while the staff surgeon stood across and took him through each step.

On his instruction the circulating nurse passed a rectal tube into the anus, guiding it up as high as it would go.

“We better start,” he said to the probationer who was scrubbed, gowned, and gloved on the other side of the table, ready to assist him. Her faint pockmarks were hidden by cap and gown. Even though her lids were puffy, she had beautiful eyes. “We can't finish if we don't start so we better start if we're to finish, yes?”

A very large incision should be made

—of small ones in such cases be afraid—

The coil brought out, untwisted by a turn

—a clockwise turn as you will quite soon learn—

And then a rectal tube is upward passed—

Thereon there issues forth a gaseous blast …

With the colon swollen to Hindenburg proportions it would be all too easy to nick the bowel and spill feces into the abdominal cavity. He made a midline incision, then deepened it carefully, like a sapper defusing a bomb. Just when panic was setting in because he felt he was going nowhere, the glistening surface of the peritoneum—that delicate membrane that lined the abdominal cavity—came into view. When he opened the peritoneum, straw-colored fluid came out. Inserting his finger into the hole and using it as a backstop, he cut the peritoneum along the length of the incision.

At once, the colon bullied its way out like a zeppelin escaping its hangar. He covered the sides of the wound with wet packs, inserted a large Balfour retractor to hold the edges open, and delivered the twisted loop completely out of the wound onto the packs. It was as wide across as the inner tube of a car tire, boggy, dark, and tense with fluid, quite unlike the flaccid pink coils of the rest of the bowel. He could see the spot where the twist had occurred, deep in the belly. Gently manipulating the two limbs of the loop, he untwisted, clockwise, just as Cope said. He heard a gurgle and at once the blue color began to wash out of the ballooned segment. It pinked up at the edges.

He felt through the bowel wall for the rectal tube that Nurse Asqual had inserted. He fed it up like a curtain rod in a loop. When the tube reached the distended bowel, they were rewarded with a loud sigh and the rattle of fluid and gas hitting the bucket below. “And down the coil contracts and you will see, the parts arranged more as they ought to be,” Ghosh said, and the probationer, who had no idea what he was talking about, said, “Yes, Dr. Ghosh.”

Ghosh flexed his gloved fingers. They looked competent and powerful—a surgeon's hands. You can't feel this way, he thought, unless you have the ultimate responsibility.

AFTER HE CLOSED, as he was stripping off his gloves, he saw Hema's face in the glass of the swinging doors. It disappeared. He charged after her. She ran, but he soon caught up with her in the walkway. She stood panting against the pillar. “So?” she said when she could speak. “It went well?”

They were both grinning. “Yes … I just untwisted the loop.” He couldn't hide the pride and excitement in his voice.

“It could twist again.”

“Well, his choice was either me or nothing, since the other doctor here would not help.”

“True. Good for you. I've got to go. Almaz and Rosina are watching the babies.”

“Hema?”

“What?”

“You would have helped if I got into trouble?”

“No, I was just stretching my legs …” Despite herself, a twinkle showed in her eyes. “Silly. What did you think?”

With Hema, even sarcasm felt like a gift. He fought the instinct to jump forward, the eager puppy too ready to forget the cuffing it had received minutes before.

“Just yesterday,” Hema said, “I drove past the spot where we saw that first hanging, and I thought about it …” She seemed to study him meditatively “Have you eaten anything today?”

That was when he noticed: His beloved, his Madras-returned, unmarried beauty, was more magnified than ever. There were succulent rolls visible between sari and blouse. The skin under her chin was gently swollen like a second mons.

“I've not eaten since you left for India,” he said, which was almost true.

“You've lost weight. It doesn't look good. Come by and eat. There's food, tons of it. Everybody keeps bringing food.”

She walked off. He studied the way the flesh on her buttocks swung this way, and that, about to sail off her hips. She'd brought back from India more of herself to love. It was the worst time for this, but he was aroused.

He dressed and found himself thinking about the operation again. Should I have tacked the sigmoid colon to the abdominal wall to prevent it twisting again? Didn't I see Stone do this? Colopexy I think he called it. Had Stone spoken to me about the danger of a colopexy and warned against it, or had he recommended it? I hope we took out all the sponges. Should have counted once more. I should've taken one more look. Checked for bleeders while I was at it. He recalled Stone saying, When the abdomen is open you control it. But once you close it, it controls you. “I understand just what you mean, Thomas,” Ghosh said, as he walked out of the theater.