Trouble Page 7

  HOW TO SURVIVE SURGERY,

  or,

  I’M PAYING TUITION FOR THIS?

  The basic principles of surviving surgery are as follows:

  no food,

  no sleep,

  No problem!

  BY HIS THIRD WEEK ON THE COLORECTAL SERVICE, JONAH had begun to feel at home among piles of guts. Once the custodial staff had removed the last copy of the Post, the residents gave up their crusade to put him in his place, and began to treat him like any other medical student: i.e., like a gimp.

  His team consisted of Yokogawa, the chief; one senior resident; two junior residents; two interns; and two third-years in addition to him. Collectively, they answered to an attending Jonah had yet to see, a mysterious and legendary surgeon named Holtz. On the ward, their team was known as Holtz Two. There were also Holtzes One and Three, whom Jonah imagined as clones of Holtz Two, so that he had not one but two doppelgängers roving the ward.

  His fellow HUMmers were Lisa Laroux, a pimply redhead with modest pediatric aspirations, and Patrick Nelgrave, a short, hirsute, belligerent gunner who came in on weekends because he was bored. Lisa was okay, but Nelgrave was a nightmare, nakedly desirous of making his peers look as stupid as possible in front of their preceptors. He used his copy of Surgical Recall—a handbook of pre-prepped pimp sessions carried by all third-years—to look up obscure facts, later just happening to “think them out loud” during rounds. What’s the difference again between Bochdalek’s and Hesslebach’s hernias? Oh right, one passes through the posterior diaphragm, frequently on the left, and the other is under inguinal ligaments lateral to the femoral vessels, riiight. Jonah learned, when asked a direct question, to answer as fast as possible; any hesitation prompted Nelgrave to barge in, brandishing his vocabulary. He was a horse thief, a double-talking backstabbing toadying panjandrum, upstaging everyone, a tactic that Jonah considered transparently juvenile until he realized that many of the surgeons were the same but with bigger mortgages and less hair. Gunners were gunners at any age.

  But this was surgery: you ate shit and declared it pâté.

  He arrived at 5:25 A.M. to preround and do scut: standing at the nurses’ station, he banged away at an ancient computer, copying vitals from the master spreadsheet and pasting them into another spreadsheet with his team’s patients. This simple-enough task often required upward of a half-hour, because the consoles weren’t networked, and without fail the overnight interns would update one console and not the others, with the result that every computer had different patient lists and different stats. It fell to the HUMmers to race around the floor, gathering the correct figures on floppy disks that they’d purchased out of pocket.

  Then came rounds. Yokogawa’s motto was Colorectal hauls ass. They didn’t spend time assuaging patients’ fears. Get the ins and outs: eat, piss, bleed, gas, shit, vomit. Heart. Respiration. Wound healing? Febrile? As soon as a patient could fend for himself, get him Off the List. OTL & OTD ASAP or SOL. The watchword was turnover. Anybody who didn’t fall into line was a Pollyanna, a sapling, deserving of an AKA (Above Knee Amputation).

  Invariably, the team had to contend with aches and pains that had bloomed, like crocuses, with the new day. While I’m here for my hysterectomy these patients seemed to say why don’t I develop a bad rash, as well? Or how about conjunctivitis? I could get pneumonia, if you’d like. Patients praying and braying and clutching their liver-spotted hands to their sagging breasts. They had halitosis and flaky skin and creeping cancers that would kill them sooner or later. They went incontinent and shried about the blandness of their meals. They got annoyed when you couldn’t bask in their reminiscences. Crotchety old-timers ripped straight from the pages of The House of God, they confirmed what his father had once told him: every branch of medicine was a subspecialty of geriatrics.

  Jonah (or Lisa or Nelgrave, always frickin Nelgrave) would stand at the foot of the bed, discoursing animatedly on sphincter muscle tone and the state of the patient’s rectal vault, which he imagined as bolted down with a mammoth brown padlock. The documents are in the rectal vault, 007, set to self-destruct. Guaiac before it’s too late.

  The medical student’s real job during rounds, however, was to carry the Bucket, a turquoise emesis basin filled with gauze, dressing, scissors, syringes, gloves. Tegaderm patches in three sizes; if the resident called for a medium, and all you had was small and large, the world screeched to a halt as you sprinted to the supply closet. Lots and lots of Surgilube. Especially on colorectal. Yokogawa would stick out his glove. Lube me, Superman. Jonah felt like a hot dog salesman.

  He felt lucky if he had time to wolf down a granola bar while jogging to the OR. Often not, which left him standing, unfed, through eight or ten hours’ worth of colecystectomies, rectal polyp removals, appendectomies. He snipped and sutured and suctioned and retracted. Up to his elbows in ligature, he learned, first, the two-handed knot; then the one-handed knot; and then spent a whole surgery woozily considering the philosophical implications of a no-handed knot.

  On colon resections he wielded the staple gun, a device that looked like an early-80s rendition of “futuristic weapon.” Preparing to fire it would say in its creepy electronic voice. The attending would nod, and Jonah would pull the trigger.

  Firing!

  And lo, the Bowel was One.

  He met a lot of surgeons. There was Kurt Bourbon, who came in twice a week to work in eighteen-hour blocks, a schedule that freed up Tuesday, Thursday, Friday, Saturday, and Sunday for the pursuit of extramarital affairs. There was “Phat” Albert Zakarias, the Hip-hop Doctor, who liked to operate while hollering along to “Real Niggaz Don’t Die.” There was Elliot Steinberger, who—though lanky, balding, and potbellied—had clearly once strutted Lothario, his yearning for the bygone manifest in long rants about how unbearably hot he found his daughter’s friends. They were thirteen. Was that wrong?

  In the afternoon, the calendar gurus printed up the following day’s OR schedule, which privacy laws forbade circulating. Anyone who wanted the information, attendings and residents included, had to come to the nurses’ station to read the master. What actually happened was that Jonah’s team sent him to make Xeroxes, a blah task made challenging by the fact that, most days, he had to do it while fending off a mob of neurotic HUMmers sent by their teams, all grabbing at the blue-vinyl binder, trying to locate the lists for their surgeons and get them into the copier that wouldn’t start without a solid hipcheck. Ever fastidious, the HUMmers invariably made extras, which got left in the paper tray or tossed, unshredded, in the trash—thus annihilating any semblance of privacy and along with it the whole point of having a master copy.

  Before evening rounds he redid the morning’s charts, noting daytime vitals and whatever lab results had come in. Writing labs was like memorizing pi. It went—

  Kim, Hyun Joo Sodium 135 Potassium 3.9 Chloride 101

  Blackwell, B. Sodium 144 Potassium 4.2 Chloride 106

  —for thirty values per patient.

  The work got interesting when a patient registered numbers through the roof or the floor. Then at least he could marvel at the remarkable elasticity of the human body, and the fact that the poor jerk would be dead before prime time.

  He swam in jargon: drowned in abbreviations. ABG, BIH, COPD, DDx, EGD, FAP, GERD, HCT, IBD, JVD, LLQ, NGT, ORIF, PICC, SBO, TURP, VAD, XRT, ZE. Words he thought he knew took on new meanings. “Cabbage” wasn’t a soup-or-salad vegetable; it was a Coronary Artery Bypass Graft. “Fast” wasn’t a rate of motion; it was a Focused Abdominal Sonogram for Trauma. PERRLs and SX and PEEPS and HOs; he was living in a rap video.

  As in the argot of superstitious old women, cancer became CA. Centimeters were sauntimeters, like the hospital had imported a shipment of the word from France. A sucking vortex of MediCode, a pit of incomprehensibility separating the patients from the healers, the uninitiated from the elect, a burdensome and privileged vocabulary that, once accepted, rendered real-world conversation impossible. No wonder
doctors married nurses or other doctors. After this there was no real world.

  Here, you accepted the outlandish. Here, humanity distilled down to a dying child; a patriarch with grasping heirs. The staff, the patients, the families: everyone playing roles, having taken their cues from melodramatic films. To Jonah the suspense of watching someone’s lungs work outdid any fiction. Such drama—real drama—made it all the more preposterous that the residents spent their free time in the lounge, watching TV shows about being a resident.

  He got pimped senseless. He took abuse. He excused surgeons their gruffness and arrogance. They had to fend off malpractice and maintain their mortality ratings; they had to worry about hotshots with steadier hands. As an eyewitness, Jonah could appreciate their miracles in a way that patients—who went under feeling crappy and woke up feeling worse—could not. He wanted to be a part of this world, and yet did not. He hoped he appeared more confident, more competent, than he felt. He was tired. He was a furnace of guilt. He wondered how he would survive. All in a day’s work.

  WEDNESDAY, SEPTEMBER 1, 2004.

  COLORECTAL SERVICE, WEEK THREE.

  The final patient of that morning was a seventy-five-year-old Hungarian man whose wife hovered by his bedside, intimidating entrants with her considerable beehive. Mr. Szathmáry was pre-op but had been hogging a bed for a day and a half, a curious luxury in the days of managed care. His prolapsed rectum and ill temper had rapidly earned him the designation “the asshole whose asshole fell out of his asshole.”

  They entered the room with one goal: to get him to sign his consent form. Instead they found themselves sparring with Mrs. Szathmáry, who insisted they had no right to take away her husband’s breakfast.

  “I brang for him,” she said, waving a Tupperware tub of lekvar pierogies.

  “That’s very sweet of you,” Yokogawa said, “but it’s not good for him.”

  “He has not eat,” she objected, reaching for the box as Jonah spirited it into the hallway and handed it off to a confused janitor.

  Jonah returned to hear Gillers, the intern, explaining that, despite his crushing hunger, her husband had to fast this morning.

  “He can have something to drink if he wants,” Gillers said, “but no solids.”

  “He can have water?”

  “Water is fine, yes.”

  “Tea?”

  “Uh. Well, it’s better, ma’am, if—”

  “Juice?”

  A purpling Lisa Laroux ate her fist. Nelgrave wiped his nose and took notes.

  “He can have ice chips,” said Yokogawa.

  Mrs. Szathmáry said, “Maybe leettle toast?”

  “No, ma’am, no toast.”

  “Why no.”

  “Toast isn’t a liquid.”

  “Hajna, Hajna,” said Mr. Szathmáry. “Maradj cs…ndben…”

  “My husband say heess hungry.”

  “Let’s please run over the procedure,” said Yokogawa.

  This, too, took longer than usual. Mrs. Szathmáry, translating, kept leaping in to editorialize or to pelt the doctors with questions. Why did they have to put him under? Was it dangerous? Was the procedure necessary? Where did they get their degrees? Were they married? She had a bad headaches, they could prescribe her to help with?

  Yokogawa said, “And once we’ve reattached the rectum to the anus—”

  “Ainus?”

  “Uh—yes.”

  “Whatsis ainus?” She sort of sounded like she was saying hyenas, and Jonah imagined the surgeon sewing a wild dog to Mr. Szathmáry’s butthole.

  “His, uhum.” Yokogawa looked around helplessly.

  “I don’t know whatsis ainus.” She turned to her husband. “Ainus?”

  It was obvious to Jonah that he was the one best holding it together. Huberman was engrossed in his armpit. Gillers looked like he wanted to punch himself in the face. Stricken with a coughing fit, Lisa Laroux had left the room.

  “The anus,” said Nelgrave, “is the opening at the inferior end of the alimentary canal, open during defecation but closed at other times. Rectal prolapse, in contrast to mucosal prolapse, involves—”

  Mrs. Szathmáry’s hearing aid shrieked, causing them all to jump. Her husband scratched at her shoulder and pointed to her ear. She turned it down, then addressed him with teary vehemence, until Yokogawa, having had enough, said, “Mrs. Szathmáry.”

  “He need ainus?”

  “Very much.”

  She conveyed this information to her husband, who grunted assent and feebly shook Yokogawa’s hand.

  Gillers muttered, “For God’s sake.” Nelgrave wrote that down.

  VIK SAID, “I’m calling on behalf of my girlfriend.”

  Native to Brookline, Massachusetts, Vikram Rakhe was laconic, dry, rational—all qualities desirable in a future trauma surgeon. A two-time winner of the New England Teen Tennis Invitational, he’d first walked into anatomy lab wearing a warm-up jacket embroidered with his club seal and, below it, his nickname: The Boston Brahmin.

  I think we’re sharing a cadaver. Holding up a sheet.

  Over the last two years Jonah had come to appreciate his paternal mien. He was a good lab partner, reliable and knowledgeable, always letting others take their share of credit even when he was the only one who’d done the reading. He nicely countervailed Lance; around Vik, Jonah got to enjoy being the loose cannon.

  The girlfriend in question was a management consultant who traveled five days a week. Jonah, copying Pontebasso, Salvatore’s T-cell count, couldn’t remember where she was at the moment.

  “Omaha.”

  “What’s in Omaha.”

  “Nothing,” Vik said. “That’s why they need a consultant.”

  The plan was to go skiing. Deanna had found a prime rate on a Vermont cabin for the first week of break. Vik intended to call some of their other classmates, Olivia and Jeremy and Harold and Anita. It would be fun.

  Jonah thanked him but declined. “I’m busy.”

  “You’re going away?”

  “I’m staying with Hannah.”

  “Mm.” To an untrained ear he might have sounded indifferent, but Jonah got his sympathy. As usual, Vik gracefully changed the subject. “Did you get my flowers?”

  “Thanks.”

  “You’re welcome. Take a lesson. How’s surgery?”

  Jonah gave him the five-minute summary, sharing tips for when Vik came through St. Aggie’s in the spring.

  “Always carry a chart. That way, someone tells you to go do something, you can say, ‘Sure thing, as soon as I’m done with this chart…’”

  “Clever.”

  “Do the busywalk. You know the drill, I’m sure it’s the same on medicine.”

  “Pretty much.”

  Jonah briefly considered mentioning Eve Gones. So far he’d told no one, and that she had not returned in the last four days seemed to confirm his earlier suspicions: what happened happened: a one-off. Even now, as his jaw sawed indecisively, he felt the heat she’d conjured up—in one stroke, like a match igniting—burning down, intensifying as it reached the end of its pathetically short life.

  He said, “Tell Deanna thanks for thinking of me.”

  “I will.”

  Ten minutes later a nurse poked him in the arm. “Some guy here for you.”

  She nodded toward the elevator bank, where a stocky man in shorts and a purple messenger bag stood cracking his knuckles. Jonah went over. “Can I help you?”

  “Jonah Stem?” The guy fiddled inside his bag and withdrew a sheaf of papers, which he thrust into Jonah’s hands.

  “Consider yourself served,” he said. Then he smiled and walked away.

  Jonah said, “What?” but the guy was gone.

  He felt as though someone had tossed him a dirty diaper that he idiotically continued to hold. Several nurses—along with an attending who was grading him—were staring at him. Served was a word he associated with restaurants and hotels, people working to make your life easier. Although he wa
s pretty sure that his had just gotten harder.

  • 8 •

  “WELL,” SAID BELZER, “no good deed.”

  “This is not—not—not right.”

  “Stop pacing, kiddo, you’re going to give yourself a stroke.”

  “They’re suing me?”

  “Hang on a minute. Don’t let’s get carried away. Nobody’s sued you yet.”

  “What do you think that is.”

  “As far as I’m concerned, a lawsuit’s not a lawsuit till the other guy’s won. Until that it’s wishful thinking.”

  “I didn’t do anything wrong.”

  “Of course you didn’t, b—”

  “Did I?”

  “No. You didn’t. Will you siddown? Siddown. Thank you.” Belzer touched his phone. “Mandy, can we hydrate my client here? Perfect. Now. Let’s focus on the positives. First of all, you got your health, don’t undervalue that. And you’re in the clear, criminally speaking. Downtown called this morning. The cops talked to the hospital. Everyone gives you a thumbs-up. The DA’s never going to gimme a guarantee, but I’d put the odds of them charging you at about two hundred to one.”

  The relief Jonah felt startled him. Fear of incarceration had gotten lost in a thicket of more dominant anxieties. “Thank you.”

  “My pleasure. Now let’s talk about the Iniguez family. The brother, what’s his—can I have th—thank you.” Belzer put on his reading glasses. “Simon Iniguez. See-moan. He has a thingy over the O. Isn’t that a girl’s name?”

  The door to the office opened, and a willowy blonde entered with a tray of Fiji water, which she set on a wooden folding table. She smiled at Jonah and slipped out. Belzer held out a bottle.

  “From now on, nobody hands me anything.”