17
The instruments nurse gives me a tiny-headed scalpel. I pull it lightly down the center of the newly inked line on Squillante’s abdomen, causing the ink, iodine wrap, and skin to spring apart about an inch. For a second, before the cut fills with blood, its fatty walls look like cottage cheese. Then I hand the scalpel back. It won’t be used again this operation. Scalpels cut cleanly, but they can’t stop bleeding.
Friendly says “Clamp.”
I say “Bovie and suction.”
A “Bovie” is an electrocautery, a device shaped like a pen with a cord coming out the back and strip of metal extending from the tip. It looks like a tiny cattle prod, so it’s unfortunate that “Bovie” is the name of its inventor, and not short for “bovine.”
A Bovie not only cuts but also burns, so it closes blood vessels as you go. (It also leaves a trail of ugly carbonized flesh, which is why you don’t use it to cut skin.) The idea is to suction the blood out of the incision, then quickly spot the cut ends of the arteries and use the Bovie to fry them shut. You have to do it fast, because suctioning only gives you a split second of visibility. Then it’s all just blood again.
I hand the suction to my student, who won’t look as stupid overusing it. Every time the student sucks the blood out, I wait until the tiny dots of blood appear, then pick one and try to electrocute it before it goes back to spurting.
At this rate the operation will take several days, and on top of that my periods of consciousness and unconsciousness are starting to alternate, lasting a thousandth of a second each, like the peaks and troughs of a radio signal. Sweat drips off my forehead into Squillante’s incision.
Eventually Friendly gets bored and starts poking around with his “clamp,” which looks like a pair of needle-nosed pliers. He grabs at arteries I can’t see, so that all I have to do is touch the Bovie to the metal of his instrument and fry the arteries by conduction, on faith.
When the bleeding’s stopped, Friendly jabs down into the gunky membrane at the bottom of the incision and spreads the jaws of his clamp, tearing the membrane apart. Then he picks out some more vessels for me to burn.
As he does so, Friendly looks at the instruments nurse, who’s a black man in his twenties. “So I can’t say ‘gay’ in the OR,” Friendly says. “Too many fragile people in here. I need to ask permission first. I forget the whole thing’s collaborative now.”
The instruments nurse doesn’t respond, so Friendly turns to my med student. “You know what ‘collaborative medicine’ means?” he says.
“No, sir,” the student says.
“It means an extra ten hours of unpaid bullshit a week. Look forward to it, kiddo.”
“Yes, sir,” the student says.
Friendly turns back to the instruments nurse. “Can I say ‘black’ in here? Or do I have to say something else?” He pauses. “How about ‘the artists formerly known as Negroes’? Can I say that? Or do I need to ask permission to say that, too?”
Operating rooms, I should say, along with construction sites, are the last safe havens for sexists, racists, or anyone else with a Tourette’s-like condition. The idea is that harassing people teaches them to stay calm under pressure. The reality is that sociologists could study ORs to learn what workplaces were like in the 1950s.
“What do you say, Scott?” Dr. Friendly says to the instruments nurse.
The instruments nurse looks up at him coolly. “Are you talking to me, Dr. Friendly?”
“If I am, I have no idea why,” Friendly says. He tosses his bloody clamp right into the middle of the instruments tray. “That’s it. Let’s open up.” He digs his fingertips into the incision, then leans over and tugs it wide like an enormous leather change purse. You can see Squillante’s beet-red abdominal muscles, which have a bright white stripe down the middle where we’ll make the next incision, because this stripe has almost no blood supply.
“Sister Mary Joseph negative,” Friendly calls out to the circulating nurse, who’s now at the computer. “There’s also no Virchow’s node, though you’ll have to take my word for it.”*
I Bovie along the white stripe.
“Will you be using Japanese or American lymph-node guidelines?” my med student asks.
“That depends,” Friendly says. “Are we in Japan?”
“Sir, what’s the difference?” my other student asks, from the floor.
“In Japan they spend all day hunting down nodes for preventative resection,” Friendly says. “Because in Japan they have socialized healthcare.” He pulls the twin bands of muscle apart. “Retractor,” he says. “We’re in the abdomen.”
The instruments nurse starts assembling the retractor, which is a large hoop that can be locked into place to hold the incision open.
While we wait, Friendly looks back at the student who’s not scrubbed in. “Don’t worry, we’ll get the socialized stuff over here soon enough,” he says. “Stacey. You want to check my beeper?”
“Sure, Dr. Friendly,” Stacey says. “Where is it?”
“In my pants.”
Suddenly there are a lot of downturned eyes in the room. Stacey gamely walks over and pats Friendly’s ass.
“Front pocket,” he says.
As I think I’ve mentioned elsewhere, scrub pants and shirts are reversible. So that while the back pants pocket is on the right, outside your pants, the front one’s on the left, inside your pants.
Stacey reaches under Friendly’s surgical gown and roots around his crotch. She wrinkles her nose at me while she’s doing it, in a way that’s actually fairly winning.
“There’s nothing there,” she finally says.
“We already knew that,” the scrub nurse says.
Everyone laughs uproariously. Friendly turns red, then blotchy, above his mask. He grabs the retractor out of the instruments nurse’s hands and wedges it roughly into Squillante’s abdomen.
“You know what?” he says when it’s in place. “F*ck all of you. Let’s get to work.”
We do. For a while, all you can hear is the beeping of Squillante’s EKG. To me, each beep feels like an alarm clock after an eternity of restless sleep. My Assman-injected forearm is starting to twitch.
But we’re making progress, at least. First we pile through Squillante’s intestines, each loop of which is anchored to a thin sheet of tissue that supplies it with blood and so on. So that while they can slide all over each other, like sharks in a tank, you can’t just unspool them like a rope. You have to leaf through them, like the pages of a Rolodex, or a phone book.
“Give me some reverse Trendelenburg,” Friendly says.*
The reverse Trendelenburgness helps us finish folding the intestines out of the way, and at last reveal Squillante’s stomach.
As with the initial incision, the complexity here will not be in removing the stomach, since any Aztec priest could take out five of them and be on the links by noon. The difficulty will be in controlling the bleeding—finding and cutting off the dozens of arteries that enter the stomach like the spokes of a wheel—so that Squillante doesn’t die. Friendly picks up a second Bovie and starts picking out arteries on his side as I work on mine.
“Funny stuff, you a*sholes,” Friendly starts up again, suddenly. “How many years of training do I have? Eleven? Fifteen? More, if you count high school. For what? So I can spend all day with a bunch of uneducated morons, breathing in genital wart particles from the Bovie and watching my salary go to my ex-wife and half the HMO executives in America. I mean, you people breathe the particles in too. But still.”
His movements are getting a little jerky. Or else maybe that’s just my rapid sleep-wake cycle.
“Oh, but that’s right,” Friendly says. “I get to save people. People like this pinkie ring a*shole, who’s spent his whole life eating beef and smoking cigarettes, and sitting on his ass.”
I say, “Suture,” and start tying off one of the larger arteries. The stitch breaks in my hand. I ask for another one.
“The f*cking beef industry and the f*cking HMO industry,” Friendly says. “Al-Cowda and the HMOsamas. They make my life hell while other people slack off. I bet tobacco’s a lot of fun. All kinds of things I never did are probably fun. Like when I was in med school, and you all were out in the park, smoking weed and listening to Marvin Gaye while you f*cked each other.”
This time I tie my stitch more gently, and it holds. I’m surprised at how quickly the knot tying comes back to me, particularly with my forearm starting to make my fingers stiffen up. But anything someone teaches you to do first to the foot of a dead pig, then to the foot of a dead human, and finally to the foot of a live human, probably sticks in your memory permanently.
“Suture,” Friendly says. The instruments nurse gives a stitch to Friendly, but it gets tangled in Friendly’s fingers, and Friendly angrily shakes it off into Squillante’s open abdomen.
“You know what I should have done?” Friendly says. “I should have been a snake handler. It’s the same job but the pay is higher. Instead I save the lives of people who hope they’ll die on my table so I can get the shit sued out of me. Because that’s all anybody wants: a chance to take a queen out with a pawn.”
“Dr. Friendly?” the scrub nurse says.
“What?” Friendly says.
“Who’s the queen in this scenario?”
There’s another round of mask-hidden laughter.
“F*ck you!” Friendly says, grabbing up the knotted length of stitch and throwing it at the scrub nurse’s face. It’s too light to make it that far, though, and it arcs toward the ground.
For a second none of us realize that Friendly’s other hand has plunged his Bovie into Squillante’s spleen.
Not just into it, either. Along it, slicing as it went. As we watch, the incision beads with blood, then starts to gush.
“Oh, f*ck,” Friendly says, yanking the Bovie free.
The spleen is essentially a bag of blood about the size of your fist, to the left of your stomach. In seals, whales, and racehorses it’s large and holds an extra supply of oxygenated blood. In humans it mostly strains out old or damaged red blood cells, and also has places where antibodies can go to clone themselves when they get activated by an infection. You can live perfectly well without a spleen, and people who survive car crashes or have sickle-cell anemia frequently do. But you don’t want to rupture it suddenly. Because almost as many arteries lead to the spleen as lead to the stomach, so losing blood from there can kill you fast.
Friendly rips the Bovie out of its power source and throws it to the ground, shouting “Give me some clamps!”
The scrub nurse calmly says “Bovie down,” and tosses a handful of clamps onto the tray. Friendly grabs a couple and starts trying to pull the edges of the spleen wound together.
The clamps tear right out, taking most of the surface of the spleen tissue off with them.
Squillante’s blood starts to pulse out in sheets.
“What’s happening?” the anesthesiologist yells from the other side of the curtain. “BP just dropped ten points!”
“F*ck off!” Friendly says, as we both go into action.
I grab a couple of clamps myself and start hunting out arteries. Just the biggest ones, since they’re all I can see through the fountaining blood.
Friendly doesn’t hassle me when I clamp the left gastroepiploic artery, which runs toward the spleen along the bottom of the stomach. I’m not sure he even notices. But when I go for the splenic artery itself, which comes off the aorta like a spigot, he swats my hand away, causing me to almost kill Squillante outright.
“What the f*ck are you doing!?” he yells.
“Hemostasis,” I tell him.
“F*cking up my arteries, more like!”
I stare at him.
Then I realize that he actually thinks it’s possible to save Squillante’s spleen, rather than tying it off and removing it.
Because if he saves it he won’t have to report slicing it open as a complication.
The alarm goes off on Squillante’s blood pressure monitor. “Get him under control!” the anesthesiologist yells.
Leading with my shoulder in case Friendly gets rambunctious again, I try once more for the splenic artery, and this time I get it closed off about an inch downstream of the aorta. The blood loss out the spleen slows to a wide, shallow leak, and the blood pressure alarm shuts off.
“Suture and needle,” Friendly says through his teeth.
Friendly starts to sew the wreckage of Squillante’s spleen into an ugly little lump. Halfway through, the needle breaks off.
“Stacey!” Friendly screams. “Tell those f*ckers to learn to make sutures, or I’m going to Glaxo!”
“Yes, doctor,” Stacey says from somewhere that sounds far away.
The next stitch holds better, or Friendly doesn’t yank on it as hard or something. “Can I have one of my arteries back now?” he asks me.
“It’s not going to hold,” I say.
“GIVE ME THE F*ckING SPLENIC.”
I separate the handles of the clamp that’s holding the splenic artery closed. The spleen slowly reinflates.
Then it splits in half along either side of the sewn-up incision, and sprays blood everywhere. As Friendly hurls the clamp in his hand against the wall, I reclose the splenic artery.
“Clamp on the floor,” the instruments nurse says casually.
“I’m taking the spleen out,” I say.
“F*ck you. I’ll do it,” Friendly says.
“I want to transfuse,” the anesthesiologist says.
“Fine!” Friendly yells at him. “Hook him up, Constance.”
Constance opens up a Coleman ice chest that says “Friendly” on it in permanent marker, and pulls out two bags of blood.
“Is that shit cross-checked?” the anesthesiologist asks.
“Do your job,” Friendly tells him.
Together, Friendly and I remove Squillante’s spleen. It takes about an hour and a half. Friendly then orders one of my med students to run it down to Pathology, so that he can later claim he took it out on purpose, looking for cancer. Which I have to admit is a nice recovery.
After that, the actual removal of the stomach is slow but mindless. We’ve already whacked half the arteries in Squillante’s abdomen. There’s nothing left to bleed. He’s lucky he still has blood going to his liver and colon.
Reconnecting the esophagus to the intestine is more irritating, like sewing two pieces of cooked fish together. But even that gets done eventually.
“Go ahead and close,” Friendly finally says to me. “I’ll go do the op report.”
Closing will take at least another hour, and I’m as tired as I’ve ever been in my life. Plus the fingers of my right hand are cramping almost to the point of uselessness.
But I’d rather close Squillante up alone than with Friendly. There are so many layers in the human body that even a good surgeon will skip sewing some of them up if the operation’s running late. As long as the layers closest to the surface are done, the patient won’t know the difference. They’ll just be more likely to rupture later on.
And I, for one, want Squillante trussed as tightly as possible. Snug and waterproof as a latex dress.
When I finally stumble out of the operating room, Friendly’s standing in the hall, drinking a Diet Coke and stroking the ass of a frightened-looking nurse.
“Remember to will the thrill, kid,” he says to me.
I’m not even sure if I’m awake. I’ve gotten through the last half hour by promising myself I’ll lie down the second I can. So maybe I already have and am now dreaming.
“You’re out of your f*cking mind,” I say.
“Then I’m lucky this isn’t a democracy,” he says. “It’s an ass-kisstocracy. And I’m the king.”
This last part he says to the nurse. I don’t care.
I’m already staggering past him down the hall.
I wake up. There’s an alarm going off like a truck backing up. Also a bunch of voices.
I’m in a hospital bed. I have no idea why or where. Every wall except the one behind me is a curtain.
Then my beeper and the alarm on my watch go off at the same time, and I remember: I lay down for a twenty-minute nap. In the recovery room. In the bed next to Squillante’s.
I jump up and swat aside the curtain between his bed and mine.
There are people all around him. Nurses and doctors, but also, near the foot of the bed, a pack of civilians. Aggressive family members, I figure, come to see how it has all turned out. The noise level is incredible.
Because Squillante is coding.
As I watch, his EKG stops jagging all over the place and flatlines, setting off yet another alarm. The medical people shout and throw hypodermics to each other, which they jab into various parts of his body.
“Shock him! Shock him!” one of the civilians yells.
No one shocks him. There’s no point. You shock people whose heart rhythm is wrong, not absent. That’s why they call it “defibrillating” instead of “fibrillating.”
As it is, Squillante stays dead. Eventually the ICU a*sholes start giving up, and pushing the civilians away to have something to do.
I try to figure out which civilian is Jimmy, the guy whose job it is to get Squillante’s message about me to David Locano in the Beaumont Federal Correctional Complex in Texas. My money’s on the guy in the three-piece suit who’s already pulling out a cell phone as he leaves the recovery room. But there are other contenders as well. Too many to do anything about.
So I go to the head of the bed and tear off the printout from Squillante’s EKG machine. It’s perfectly normal up to a point about eight minutes ago, where it starts spiking all over the place.
The spikes aren’t even close to normal. They form a bunch of “M“s and “U“s, like they’re trying to spell “MURDER.” I pick up the red “biohazard” bin and take it back around the curtain to where I was napping. Dump it out on the bed.
Even with all the used syringes and bloody gauze squares, it doesn’t take long to find the two empty vials that say “Martin-Whiting Aldomed” on them.
And which used to be filled with potassium.