In his admission physical, Bartholomew had noted a number of bruises on the woman's arms and legs, but elected nevertheless to proceed with a D and C-commonly done for excessive bleeding. He did not order blood clotting studies until after his patient's bleeding worsened postoperatively. Now, with the woman loaded with fresh clotting factors, Bartholomew was repeating the curettage. Beverly Vitale, a thin, delicate young cellist with straight jet hair and fine, artist's hands lay supine on the operating table with her eyes taped shut and her head turned ninety degrees to one side. A polystyrene tube placed through her mouth into her trachea connected her with the anesthesia machine. Her legs, draped in sterile sheets, were held aloft by cloth stirrups hooked beneath each heel. Overhead, in the observation gallery Tom Engleson watched and waited. He was dressed in standard operating room whites, with hair and shoe covers, but no mask. As he watched the level of suctioned blood rise in the vacuum bottle on the wall, Engleson wondered if D. K. Batholomew was considering removing the woman's uterus altogether. He cursed himself for not throwing protocol to the winds and inviting himself into the OR. The prospect of the old surgeon moving ahead with a hysterectomy brought a ball of anger to the resident's throat. Much of his reaction, he knew, had to do with Beverly Vitale.
Though he had only spoken with her a few times, Engleson had begun fantasizing about her and had become determined to see her when she was released from the hospital. Now his thoughts added, if she was released from the hospital. He glanced again at the vacuum bottle and then at Bartholomew. There was a flicker of confusion and uncertainty in the man's eyes. 'Her pressure is dropping a bit.'
Engleson heard the anesthesiologist's voice crackle through a barely functional speaker on the wall behind him. 'Young lady, get me the freshest unit of blood we have, and see if the blood bank can send us up ten units of platelets.'
'Yes, sir, ' the nurse said. 'Dr. Bartholomew, blood loss so far is four hundred and fifty cc's.'
Bartholomew did not respond immediately. He stood motionless, staring at the steady flow of crimson from Beverly Vitale's cervix.
'Let's try some pitocin. Maybe her uterus will clamp down, ' he said finally. 'Dr. Bartholomew, ' the anesthesiologist said, an even tenseness in his voice, 'you've already ordered pitocin. She's been getting it. Maximum doses.'
Engleson strained to see the older surgeon's face. If he rushed into the OR and the man did not need assistance, a formal complaint was' sure to … Before he could complete the thought, the bellboy hanging from his waistband emitted the abrasive tone signaling a transmission. 'Dr.
Engleson, call two eight three stat. Dr. Engleson, two eight three stat, please.'
An anxious check of the scene below, and the resident rushed to the nearest phone. It was a rule of the Ashburton Service that all stat pages were to be answered within sixty seconds. Telephones had even been installed in the residents' bathrooms for such purposes. The call concerned a postop patient whose temperature had risen to 103, not a life-or-death situation. By the time Engleson had listened to the nurse's report, given orders for evaluating the patient's fever and returned to the observation window, Bartholomew had begun swabbing antiseptic over Beverly Vitale's lower abdomen. Engleson switched on the microphone by his right hand. 'What's going on? ' he asked. Below, no one reacted to his voice. 'Can you hear me? ' Again no response. Through the door to the scrub area, Engleson saw Carol Nixon, a surgical intern rotating through the Ashburton Service, beginning to scrub. Apparently Bartholomew had called her in to assist, perhaps when Engleson could not be found.
'Over my dead body, ' Engleson said as he raced down the hall to the stairs. 'No way do you open that woman up without my being there.' In less than a minute, he had joined Nixon in the scrub room. 'The nurses said Stone Hands was trying to find you, ' the woman said. 'I was just finishing up a case down the hall when Denise grabbed me. Do I have to stay?'
'You might want to learn from the master in there, ' Engleson responded acidly, cleaning his fingernails with an orange stick. The intern smiled, nodded a thanks-but-no-thanks, and left him to finish his scrub.
'Order a peach and you get a pear, ' was Bartholomew's comment on the change in assistants. He laughed merrily at his own humor and seemed not to notice the absence of response from around the room. With Engleson handling sponges and hemostats, Bartholomew used an electric scalpel to make an incision from just below Beverly Vitale's navel to her pubis.
The scalpel, buzzing and crackling like hot bacon grease, simultaneously sliced through the skin and cauterized bleeding vessels. Next, with the voltage turned up, he cut through a thin layer of saffron-colored fat to her peritoneum, the opaque membrane covering her abdominal cavity. A few snips with a Metzenbalim scissors, and the peritoneum parted, exposing her bowel, her bladder, and beneath those, her uterus. In a perfunctory manner, too perfunctory for Engleson's taste, the older surgeon explored the abdominal cavity with one hand. 'Everything seems in order, ' he announced to the room. 'I think we can proceed with a hysterectomy.'
'No! ' Engleson said sharply. The room froze. 'I mean, don't you think we should at least consider the possibility of ligating her hypogastric artery? ' He wanted to add his feelings about rushing ahead with a hysterectomy in a thirty-year-old woman with no children, but held back.
Also unsaid, at least for the moment, was that the hypogastric ligation, while not always successful in stopping hemorrhaging, was certainly accepted practice in a case like this.
Bartholomew was still guided by the old school-the school that removed a uterus with the dispatch of a dermatologist removing a wart. D. K.
Bartholomew's pale blue eyes came up slowly and locked on Engleson's.
For five seconds, ten, an eerie silence held, impinged upon only by the wheeze of air into the vacuum apparatus. The tall resident held his ground, but he also held his breath. The outburst by the older surgeon now, and there would be a confrontation that could further jeopardize the life of Beverly Vitale. Then, moment by moment, Engleson saw the blaze in Bartholomew's eyes fade. 'Thank you for the suggestion, doctor,
' the surgeon said distantly. 'I think perhaps we should give it a try.'
The relieved sighs from those in the room were muffled by their masks.
'You or me? ' Engleson asked. 'It… it's been a while since I did this procedure, ' Bartholomew understated. 'Don't worry, we'll do it together.'
In minutes, the ligation was complete. Almost instantly, the bleeding from within the woman's uterus began to lessen. 'While we're waiting to see if this works, ' Engleson said, 'would you mind if I got a better look at her tubes and ovaries?'
Bartholomew shrugged and shook his head. Engleson probed along the fallopian tubes, first to one ovary and then to the other. They did not feel at all right. Carefully, he withdrew the left ovary through the incision. It was half normal size, mottled gray, and quite firm. This time, it was his eyes that flashed. You said everything was in order.
Bartholomew sagged. There was a bewildered, vacant air about him, as if he had opened his eyes before a mirror and seen a painful truth. The woman's right ovary was identical to her left. 'I don't think I've ever seen anything quite like this, ' Engleson said. 'Have you? ' No, well, not exactly-, Pardon?'
'I said I hadn't either.'
There was an uncertainty, a hesitation, in the older man's words.
He reached over and touched the ovary. 'You sure? ' Engleson prodded. 'I … I may have felt one once. I'm trying to remember. Do you suggest a biopsy? ' Engleson nodded. 'A wedge section?'
Another nod. The man's confidence was obviously shaken. By the time the wedge biopsy was taken, the bleeding had slowed dramatically. As Engleson prepared to close the abdominal incision over the uterus he had just preserved, he sensed the irony of what was happening tighten in his gut. The uterus was saved, true. A fine piece of surgery. But if the pathology in Beverly Vitale's ovaries was as extensive as it appeared, the woman would never bear children anyhow. 'Denise, ' he said, 'could you find out who's on for surgical path this month, both the resident and the staff person, okay?'
'Right away.'
Engleson glanced at the peaceful face and tousled hair of the young cellist. Some women try for years to get pregnant, never knowing whether they can or not, he thought. At least you'll know. Glumly, he began to close. Twenty minutes later, the two surgeons shuffled into the doctor's locker room. 'Dr. Bartholomew, have you been able to remember where you might have encountered ovarian pathology like this woman's?'
'Oh, yes, well, no. I… what I mean is I don't think I've ever seen anything like them.'
'You look as if you want to say something more.'
'I may have felt something like them once. That's all.'
