Bellevue

Chapter 5

Monday, July 1, 11:30 a.m.

Mitt looked up at the institutional clock on the wall of OR #12 and could see that he’d been in the operating room for almost two hours. It was his first operation as a surgical resident, and it wasn’t going as well as he would have liked for multiple reasons. He was standing on the left side of the patient along with a fourth-year resident, Dr. Geraldo Rodriguez. On the opposite side was Dr. David Washington, a physically imposing vascular surgeon. The case was an excision of an abdominal aneurysm, which was a pathological outpocketing of the main artery of the body, the aorta, in the patient’s abdominal cavity below the diaphragm. The patient, Benito Suárez, was an otherwise healthy thirty-eight-year-old Hispanic male. The problem for Mitt was that he couldn’t see the operative field despite forcibly gripping the handle of a retractor with both hands. Mitt’s retractor was holding back the left side of Mr. Suárez’s incision, including some of the patient’s intestines, to expose his aorta.

Dr. Rodriguez had essentially crowded in front of Mitt, placing his right arm over Mitt’s arms in his attempt to assist the surgeon, who was currently struggling to work up under the diaphragm. This meant Mitt was being pushed against the anesthesia screen and forced to face the back of Dr. Rodriguez’s surgical gown — the operative site completely obstructed. All he could see was the wall clock by glancing upward, or by looking to the left past Geraldo’s backside, he could see the scrub nurse on her stool and facing the instrument tray. In the opposite direction and over the anesthesia screen, he could see the anesthesiologist sitting on his wheeled stool and monitoring the patient’s vital signs.

What this all meant for Mitt was that although he was physically in the operating room during what he imagined was an interesting case, there was no way he could appreciate any of the details. He had no real idea of what was going on inside the patient other than gathering that Dr. Washington was having significant technical difficulties sewing the upper portion of a graft to the patient’s aorta to replace the section that had been removed. The problem had been caused by the need to remove more of the proximal aorta than expected yet keep from going into the chest cavity.

Although Mitt couldn’t see her at the moment, there was another surgical resident standing to Dr. Washington’s right. She was a second-year resident named Dr. Nancy Wu. Mitt had been cursorily introduced to her at the same time he’d been introduced to the others by Dr. Van Dyke, who’d accompanied Mitt when he first entered OR #12. At that time the surgery had already been underway for an hour and a half. Mitt had seen that Dr. Wu was holding a retractor similar to the one Mitt was about to be handed. She was holding back the right side of the abdominal incision.

The situation was physically uncomfortable for Mitt as well as mind-numbingly boring, even though Dr. Washington would pause on occasion to explain what he was doing. But without being able to see either Dr. Washington or the operative site, it was nearly impossible for Mitt to picture what was happening. All he could do was hold on and watch the clock’s second hand as it slowly and repeatedly swept around the dial. At least the time gave him an opportunity to relive the morning.

The tour he and Andrea had been given by Dr. Van Dyke had been very helpful to quell some of their shared anxieties. Although Mitt, and Andrea to a lesser extent, had tried to break through Dr. Van Dyke’s formality and her air of superiority as a third-year resident in contrast to Mitt and Andrea’s lowly first-year status by offering personal information and asking personal questions, she’d resisted. For Mitt, it corroborated his impression of exactly how hierarchical surgery remained and how the system perpetuated itself.

The first thing Dr. Van Dyke had shown them was the on-call rooms, which were both simpler and nicer than Mitt had expected, especially with their modern en suite bathrooms and even showers. Encouragingly enough, there was also a resident lounge with a television, although both he and Andrea wondered if it had ever been used since the remote was nowhere to be seen.

Next they were given a short tour of the all-important staff cafeteria, which they were assured was open 24/7. With their every-other-night on-call schedule they would most likely be eating most of their meals there. From the cafeteria, they were taken to see all the surgical inpatient wards, where they met a lot of the day staff. Everyone from nurses to various aides and even housekeepers were super friendly and welcoming. Mitt was pleasantly surprised, particularly by the nurses. He’d always thought that they might resent the new residents, whom they would have to help become oriented. Mitt even tried to commit some of the day-shift nurses’ names to memory but soon gave up because there were simply too many. Next, he and Andrea were shown around the surgical ambulatory clinics before heading to the ICUs on the tenth floor. There, both newbies were seriously interested in the tour, but at the same time felt cowed by the state-of-the-art technology and the precarious conditions of the patients.

The final aspect of the tour had been the OR suite, including the OR lounge and locker rooms. And then, once they’d changed into scrubs, they had been shown the operating rooms and given specific instructions on how to scrub their hands before going into surgery. After that, they’d been assigned ongoing cases, with Mitt being sent into OR #12 for the abdominal aneurysm while Andrea was to join a team doing a laparoscopic gallstone removal in OR #8.

At first Mitt thought he’d won out since the aneurysm case was far more intriguing than a mere laparoscopic gallstone removal. But after two hours, Mitt’s opinion changed. Now his presence seemed more like a burden than an opportunity, underlying in real time the conflict between education and service in the hospital residency programs. After the first half hour, Mitt hadn’t learned a thing. In fact, if anything, his arrival seemed to have heralded a negative change in the OR’s atmosphere and hence the flow of the procedure.

When Mitt had first arrived, everyone on the OR team was busily engaged, seemingly finding contentment if not pleasure in their efforts, particularly with the understanding that they were literally saving someone’s life. Having an abdominal aortic aneurysm, especially a large one with a dangerously thin wall like the current patient had, was akin to having a death sentence. At any given moment, perhaps with just a bit of exertion involving the abdominal muscles, the aneurysm could rupture, instantly causing rapid exsanguination into the abdomen and almost instantaneous death.

But then, right after Mitt had joined the group and been handed the retractor, small annoying things began to occur, eventually changing the dynamic from a contented team to a group of people on edge. First the scrub nurse handed Dr. Washington a pair of dissecting scissors that were somehow not up to his standards. With irritation, he brandished the instrument in front of the scrub nurse’s face, complaining that she should have checked it, seen that it was defective, and never handed it to him. He then tossed the offending scissors over his shoulder onto the floor, evoking a negative response from the circulating nurse, who shook her head as she bent over to pick them up.

“Sorry,” the scrub nurse had said, but in a tone that suggested she wasn’t all that sorry. “I wasn’t aware there was anything wrong with them.”

“Well, you should have known,” Dr. Washington had snapped.

Mitt, who’d been in the room for only a few minutes, sensed that Dr. Washington was on edge because he was having operative difficulty, which was aggravated by the supposedly defective scissors. The surgeon subsequently did explain what the difficulties were. After he’d removed the section of the aorta with the aneurysm, which had occurred prior to Mitt’s arrival, he’d had to remove progressively more of the proximal aorta, meaning closer to the heart, because the vessel’s wall was also visibly abnormal. “That’s going to make sewing the proximal part of the graft a challenge,” the surgeon had announced, which certainly had proved to be the case.

About a half hour after the scissors incident, there’d been a bit of a mix-up between the scrub nurse and Dr. Washington during the exchange of a small piece of the aorta, which the surgeon wanted Clinical Pathology to look at and confirm it was normal enough to hold sutures. Whether this second incident was the scrub nurse’s fault or the surgeon’s was unclear, but the result was that the biopsy fell onto the sterile drapes that covered the patient and then onto the floor, requiring the circulating nurse to retrieve it.

“Good Lord!” Dr. Washington snapped. “What the hell? Pay attention, for Christ’s sake!”

“I had my hand out for the biopsy,” the nurse complained. “But you missed!”

Mitt had actually seen what had happened. The nurse did have her hand out, but as she redirected her attention to reach for the container she was going to put the biopsy in with her other hand, her outstretched hand had moved. At the same moment, Dr. Washington had prematurely looked back into the wound as he released the pressure on the forceps he’d used to pick up the piece of tissue. It was as if some nefarious spirit had willed the episode to occur.

“I’m paying full attention!” the scrub nurse said indignantly. “Are you?”

For a few tense moments, the nurse’s rhetorical question hung in the air like a bank of dark clouds threatening a summer thunderstorm. Everyone in the room held their breath, tensely wondering what kind of reaction Dr. Washington would have. Mitt would later learn that the surgeon had a notoriously short fuse. But on this occasion, perhaps tempered by the challenge at hand, he chose not to say anything further and just went back to work.

The final minor episode was the strangest of all, since Mitt believed he saw it happen yet couldn’t explain it like he could the others. Unable to see any of the operation and with his mind wandering, he found his vision did as well. One minute he’d be watching the clock, the next watching the scrub nurse, and the next glancing at the anesthesiologist, who seemed to be in his own world beyond the anesthesia screen.

Suddenly, in front of Mitt’s eyes, a pair of forceps fell from the instrument tray, causing Dr. Washington to literally jump as they hit his arm before falling onto the drapes. “What the hell?” he bellowed as he straightened up, grasped the wayward forceps, and tossed them back onto the instrument tray, whose contents the scrub nurse was continuously adjusting to make sure she could anticipate the surgeon’s needs and requests.

“What the hell are you doing?” Dr. Washington demanded, again seemingly using the minor episode to give vent to his frustrations about the case.

“I’m doing what I always do,” the scrub nurse said defiantly. “I’m trying to anticipate your needs.”

“I didn’t ask for forceps,” the surgeon snapped.

“I was loading the needle holder,” the scrub nurse responded. “I didn’t touch the forceps.”

“Oh yeah, sure!” Dr. Washington spat. “They just jumped off the instrument tray on their own accord.”

At this point in the tense exchange, Mitt tried to remember what he’d seen. At the moment of the incident, he’d been looking in the scrub nurse’s direction but with unseeing eyes because his mind had been elsewhere, worrying about his first night on call. From Dr. Kumar’s comments, he was going to be the first line of defense, and with the sheer number of patients involved, it would be a huge responsibility. To make matters worse, one of the patients he’d be covering was going to be Benito Suárez, whose difficult surgery he was currently experiencing but not seeing.

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.”