The Society

CHAPTER 2

Ashford was a bedroom community located almost midway between Fredrickston and Worcester. Beeper and cell phone at the ready, Will checked out with the ER and surgical residents and headed west through modest late-afternoon traffic. He knew that he was hardly the only divorced dad forced to drive to the house that had once been his to take his children out for dinner, but that knowledge did nothing to assuage the weirdness he invariably felt in the situation-especially when the doorbell was answered, as it was tonight, by Mark Mueller, once a friend and financial adviser to him and Maxine, and now, for more than a year, her live-in.

“Hey, how’s it going?” Mueller said, knowing better than to attempt a handshake.

Mueller, though about Will’s height and build, had a full scalp of curly hair, which invariably made Will reflect on the modest but relentless recession at the corners of his own. Max had explained that she and Mueller were too much in love not to live together but that the cost of marriage, in terms of lost alimony, made nuptials a fiscal impossibility.

Will stepped into his former foyer.

“Kids ready?”

“Danny’s just finishing up his homework. Jess is ready, though.”

Will smiled to himself. Could any pair of twins ever be more different from each other-or more wonderful in those differences? Jess always ready, Danny last minute or beyond; one meticulous, one scattered; one serious and intense, one flaky and wildly imaginative; one (Jess) an athlete, the other already credited with several community-theater productions.

Damn you, Max.

“Hey, Dad, who loves you?”

Jess, in jeans and a bulky sweater, came racing around the corner and dove into his midsection.

“Who loves you, baby. Everything okay?”

“Fine. Tammy got sent home today for throwing spitballs. Cody Block said he likes me. I got an ‘A’ on my Morocco project. Are we going to the Hearth or your place or a restaurant?”

“Hearth.”

“Great!”

“Danny, let’s get-”

The shoulder-first assault from behind, with more force than any ten-year-old should be able to generate, nearly knocked both Will and Jess over.

“Open Hearth night, right?” Danny asked.

“Right on.”

“Um. . Max wants them home by nine,” Mueller said uncomfortably.

Will’s eyes flashed. His thin smile said many things.

“Nine it will be, Mark. She at the gym?”

“Office. She should be back soon.”

“Nine. Come on, guys.”

“I keep telling you, I’m not a guy.”

“All right, come on, girls.”

“Daddy!”

Will, two classmates, and a saintly psychiatrist had started the Open Hearth Kitchen during Will’s sophomore year in med school. The idea was to survive two intense years of basic science studies by involving themselves in a project centering on real live humans. Almost immediately, the other students and faculty joined in, helping to make their efforts a success. A dynamic, visionary young director and a committed board saw to it that the merchants, schools, churches, and residents of Fredrickston and the surrounding towns understood the place and embraced it. Now, after sixteen years, there were times when volunteers had to be turned away, although none of the thousands of diners who had patronized the kitchen ever were. Three hundred and ten was the record for dinners served on one night, but with the economy continuing to nosedive, that record seemed likely to fall before long.

No matter how hard it had been to take time off from work, Will seldom missed the monthly board meetings, and almost never his serving obligation-the first and third Tuesdays of every month.

The rugged, three-story clapboard structure occupied a corner lot in the most run-down part of town. Maxine had tried insisting that the area was too dangerous to keep “dragging” the twins to, but in this debate, unlike most of the rest, Will had prevailed.

“Okay,” he said, easing his four-year-old Wagoneer into the small parking area, “you guys know the drill.”

“I’m doing dessert,” Danny called as the two raced up to the kitchen door.

“You did it last time!”

As he often did, Will paused to survey the building and to reflect on the years since the project’s inception. In the beginning, a nearby Episcopal church had rented the first floor to them for next to nothing. Now, the Open Hearth Kitchen, a tax-exempt corporation, owned the whole thing. Belief, perseverance, fearlessness-over the intervening years, the Open Hearth had come to mean so many things to him. Now his involvement was limited to board of directors’ meetings and those two nights a month as a server. His energy-what there was left of it-had instead been channeled into the Hippocrates Society and its quixotic mission of reclaiming medicine from the HMOs and insurance companies.

Belief. . perseverance. . fearlessness.

By the time Will entered the kitchen, the kids were each involved in animated discussions as they worked. He smiled at the ease with which they had made themselves part of the gang, and the genuineness with which they had been accepted. In all, this night there were sixteen volunteers and five staff. No army had ever functioned with more efficiency and esprit.

“Hey, Will, wassapnin’.”

“Same old, same old, Beano. How about you?”

“Can’t complain. Your kids are really something. Two minutes and they’re already up to their elbows in whatever needs doing.”

Benois Beane, forty-something, had been the Hearth’s director for going on five years, during which he had continued to expand the agency’s programs, instituting a Meals on Wheels service and an employment counselor. He had also taken it on himself, following an offhand remark by Will, to ensure that no one called Will “Doc.” Many knew he was a physician, but there was no reason at all to advertise the fact. The last thing he wanted was to dilute the dual pleasures of serving food to those who needed it and introducing his children to people who were light-years from the tree-lined privilege of Ashford.

“Beano, the place is looking great.”

“Yeah. Thank God for all those churches and synagogues.”

“I suppose that would be appropriate,” Will said.

Beane took a moment to find the humor, then his ebony face crinkled in a broad grin.

“Good one,” he said. “I almost missed it. Forgive me for saying this, Will, but you look as if you’ve been working too much.”

“Hell no. By my standards I’m exceedingly well rested. See me tomorrow morning. By then I’ll be looking as if I’m working too much. What you’re viewing now is totally fresh Grant.”

“Fresh Grant,” Beane echoed. “Sounds like something we should have on the menu.”

By five-thirty when the doors opened, at least fifty were lined up to be served, a number of them with young children in tow. A goodly percentage of the patrons still had a roof over their heads, but for them, food and heat were getting more and more difficult to manage. The twins had settled their conflict in house and were working side by side at the dessert section. Will, an apron tied around his waist, strolled among the tables with a soapy-water spray and a towel, chatting with the diners and cleaning up after they had left. At one table, where a particularly grizzled down-and-outer sat alone, picking at his beef stew and rice, Will stopped.

“How’re you doin’?” he asked.

The man, with metallic-blue eyes and a nose that had been broken probably more than once, forced a weak smile.

“Can’t complain,” he said.

“Name’s Will.”

“John. John Cooper.”

“I haven’t seen you here before.”

“Haven’t been.”

“Well, you picked a good night to start. Beef stew is about the best thing we do.”

“It’s very tasty.”

“Listen, John, I don’t go around advertising the fact, but I’m a doctor. I work at the hospital. Stop me if you think I’m out of line, but I’m concerned about those lumps on the side of your neck.”

Cooper didn’t bother reaching up to touch them.

“What about ’em?”

The lumps, markedly swollen lymph glands, were trouble. Will’s quick differential diagnosis included several types of cancer, as well as scrofula-a form of tuberculosis.

“Has any doctor checked them out?”

“Can’t afford no doctor.”

“You have Mass Health? Any kind of insurance?”

Cooper shook his head.

“Will you come see me and let me check those over, maybe run a few tests? It won’t cost you a thing.”

“Maybe.”

“I promise I’ll take good care of you.”

“That’s nice of you.”

Seldom more than a couple of tables behind, Will could see enough from where he stood to know he would be hard-pressed now to catch up with the influx.

“Listen, John,” he said, “I’m going to send Ben Beane over to talk with you. He runs this place. He’ll help you fill out the forms to get some state insurance, okay?”

“You mean welfare?”

“Insurance-the sort everyone in this country deserves to have. I don’t like to put labels on things, but what I’m talking about isn’t welfare. Wait here. I’ll get Ben. He’ll explain everything, and he’ll also give you my address. Okay?”

“If you say so.”

On the way over to find Beane, Will paused briefly to wipe down two tables. Most of the patrons of the Open Hearth Kitchen were respectful of the place and quick to do whatever they could to keep the tables ready for others. But some weren’t.

“Beano, I need your help with a new guy.”

“The one you were talking to?”

“He needs to come see me about some big lumps in his neck. Can you give him my address and have your people start him on the bumpy road to Mass Health coverage so we can get some tests done?”

“I would,” Beane said, “but the dude just got up and left.”

Will raced to the front door. A mean wind was sweeping through the blackness. There were a few patrons shambling toward him, but John Cooper was gone. Impotent with the situation and peeved at himself for possibly frightening the man off, Will was still on the staircase, peering down the street, when his cell phone went off. The display showed an ER number.

“Damn.”

“Will, it’s Lydia,” the surgical resident said. “Rescue just called from an alley downtown. They’re working on a guy a couple of kids found there, beaten up pretty bad. Mid-forties, robbery probably. No ID, no BP to speak of. He’s frozen, but they assure me he’s still alive.”

“ETA?”

“Ten minutes.”

There was no sense in trying to find out the location of the alley, even though it might have been nearby. In the field, the paramedics and EMTs were better and faster than he could ever be.

“I’ll be there,” he said, sensing the familiar adrenaline rush and accelerated thinking that accompanied a possible surgical emergency. “Have the CT scan people ready to do his head. Call someone in if there’s no one there right now. Two lines in, large bore, cath his bladder, get bloods off including a stat alcohol and drugs of abuse panel, type and cross-match for six units and have them be ready to do more. As soon as the bloods are off, give him a jolt of glucose. Don’t bother waiting for the sugar result before you do that. Just in case, alert anesthesia and the OR that something may be brewing.”

“Got it.”

“Oh, and, Lydia, if he’s as cold as the rescue people say he is, please have the nurses get a warming blanket ready and heat up some Ringer’s lactate solution.”

Of all the Tuesdays he had taken call while volunteering at the Hearth, this was the first time he was faced with an emergency that demanded his immediate return to the hospital, ready to race up to the OR. He went back inside, looked over at the kids, and, as he was doing for the emergency at FGH, sorted through a dozen different courses of action at the same time. Finally, knowing there was no other way, he swallowed his pride and frustration, and called Maxine.

Lydia Goldman spotted Will and the twins approaching down the hallway and raced to meet them. A third-year resident, she had never handled emergencies calmly, and Will was pleased to have learned some weeks ago that she had been accepted into a plastic-surgery program in Kansas.

“This is real trouble, Dr. Grant. His core temperature is fifty-two. He’s been beaten to a pulp. BP isn’t readable. I’m getting set to put in an arterial line.”

“Deep breath,” Will said, “now slow exhale. Kids, this is Lydia. Lydia, Dan and Jessica. The guy’s alive, right?”

“Yes, but-”

“Hold it for a second. Jess and Dan, I’m really sorry about having to cut off the night so early. Mom will meet you over there in the waiting room. I’ve got to get to work helping Lydia with her patient.”

“Can we watch?” Jess asked.

“Yuck,” Dan said.

“Another time, I promise. I’ll see you both on Saturday. I love youse guys.”

“Da-ad.”

“I know, I know.”

Will kissed each of them on the forehead, then followed Lydia into the ER. The unconscious, middle-aged man had been stripped and placed on a large warming pad. Two nurses were adjusting his IV lines and monitoring equipment. He had been beaten badly about the head, face, and chest, with some fresh bruising on his abdomen as well.

“Order some neck films, Lydia, just in case.”

“Oh, my, I’m really sorry I didn’t do that.”

The woman, a knowledgeable-enough resident in spite of her lack of cool, flushed at having made an oversight. Will paused to settle her down.

“Lydia, we do this as a team so that together we might think of everything, okay? Self-flagellation does nothing to improve our focus.”

“O-okay. I’ll be right back.”

She raced off to get spine X-rays ordered.

“Arterial line,” Will called after her, already examining the patient as he approached the bedside.

No extremity fractures. . pupils slightly dilated, not reactive to light. . probable orbital fracture on the right. . chest appears intact, moving air poorly with grunting respirations. .

“Julie,” he called to one of the nurses, “please call anesthesia down here to put a tube in this man.”

Abdomen somewhat distended, dull to percussion. . fluid?. . blood?. .

Will set his hands on either side of the man’s abdominal wall and felt the muscles beneath them tighten. Even comatose there was some reaction from John Doe. Light pressure had caused enough pain to break through his depressed consciousness.

“It’s in here,” he said to no one in particular. “I’d bet the ranch on it. Listen, everyone, as soon as we have cervical spines and a CT scan of his head, we’re going up to the OR. Someone alert them. Lydia, you’ll assist, so go scrub as soon as you can. Tell them we’re going to explore this fellow’s abdomen.”

“Do you want antibiotics?” she asked.

Will glanced up at her and pumped his fist just enough for her to see.

“Way to go,” he said. “Order whatever you think would be best.”

“Julie, two grams of Mefoxin IV, please,” Lydia said.

In minutes, the broad-spectrum antibiotic was in, and the anesthesiologist had placed a breathing tube down John Doe’s trachea. Next he inserted a third intravenous line via a “blind stick” into the internal jugular vein.

“Temp’s seventy-two,” a nurse announced. “BP is still in the twenties.”

Will glanced down at the man’s abdomen, which was more distended than even a short while ago.

“Let’s get him over to X-ray right now,” he said. “We’re running out of time.”

This was medicine the way it was meant to be, Will thought, vigorously scrubbing his hands with a hexachlorophene-impregnated brush. A patient in big trouble, a surgeon and his team prepared to act. No forms to fill out; no panel to go through.

He wished things with Maxine had worked out differently and that he didn’t spend so much of what little free time he had alone. He wished he had the kids more and the money and time for a memorable vacation with them. He longed to spend more time in the gym. But one thing he never wanted to change was the rush of this moment, focusing years of training and experience into the awesome responsibilities of being a surgeon.

Using his knee, he shoved the lever to the right, shutting off the water. Then, hands up, palms facing in, he backed into the OR, accepted a towel from the nurse, and dried his hands. Finally, he slipped into a sterile gown, allowed it to be tied, and thrust his hands into a pair of size 71?2 gloves. Time for battle.

John Doe was stretched out on the table, covered with drapes that exposed only his abdomen, swabbed in russet antiseptic. Will could see and feel that the area had become even more distended. Just before he had entered the operating suite, he had received the blood-alcohol report-negative. That result, coupled with the negative head CT, strongly suggested overwhelming infection or massive blood loss into the abdomen as the cause of the profound shock and coma.

“Ready, Ramon?” he asked the anesthesiologist, who peered over the drape separating his work space from Will’s and nodded. “Ready, everyone? Lydia? Okay, number-ten blade, please, Jennifer.”

One by one Will sliced through three of the four layers of John Doe’s abdomen.

“Suction ready,” he called out just as the fourth layer, the thin peritoneal membrane, parted beneath his blade. Under pressure, volumes of foul-smelling brown liquid spewed out of the abdominal cavity, a good deal of it overwhelming the suction and flowing down onto the floor. Will stepped back just in time to keep from irreparably soiling his trademark OR footwear-red Converse Chuck Taylor high-top sneakers.

“Whew!” the circulating nurse exclaimed. “Deodorizer?”

“Why not. And a pile of lap sponges, Jen, and more suction.”

The circulator placed two drops of deodorizer on every person’s mask. One by one, Will inspected each organ-large and small bowel, kidneys, pancreas, liver, spleen, stomach, and gallbladder, even though the source of the problem was already quite apparent. Scar tissue from chronic inflammation caused by gallstones had shut off the blood supply to the large intestine, causing a foot-long section of it to become gangrenous and finally to split, spilling feces into John Doe’s abdominal cavity. Septic shock was the result.

“Lydia?” he asked. “Where to from here?”

The resident’s eyes were red from the onslaught of the fetid spillage. Will suspected that at least a corner of her brain was imagining life as a plastic surgeon-bowel contents versus Botox. No contest.

“Isolate the diseased intestine, staple it off with a GIA stapler,” she said, “then control bleeding, irrigate the abdominal cavity clear with warm saline, and then go after the gallbladder first.”

“The artery we need to tie off to get the gallbladder out?”

“Cystic.”

“Excellent. Go ahead and locate it. You sure you want to go into plastics?” Will could tell from her eyes that she was missing the glint in his. “Don’t bother answering that,” he said.

He guided her through the removal of the gallbladder and then did the colon removal and colostomy himself. If by a miracle Mr. Doe survived this ordeal, the colostomy could be reversed some time in the future. With heavy bacterial contamination, it was best to leave the skin incision packed with dressings rather than to suture it closed. The scar would be impressive, but that, too, could be revised down the line. At the moment, it was life versus death, with death holding most of the high cards.

Finally, it was done. A procedure fraught with potentially fatal pitfalls had just been completed quickly and virtually without a hitch, and every person working in OR 3 at that moment felt part of it.

“Great job, Will,” the anesthesiologist called out as he lowered the drape. “You can take out my gangrenous intestine anytime.”

Several nurses and Lydia echoed the praise.

John Doe still remained teetering on the edge of death and was facing a multitude of potentially lethal complications if he managed to survive the hours immediately post-op. But Will felt exhilarated. The hundreds of decisions he had dealt with, instinctively or after deliberation, were holding up.

He helped transfer the man to a recovery-room bed and watched approvingly as the nurses reconnected the myriad of fluid and monitoring lines.

Maxine, the exhausting hours at work, the alimony and support payments, the periods of loneliness, the truncated time with the twins, the pressures from managed care-as long as practicing medicine could deliver as it had tonight, he would somehow find the strength to deal with the rest.