Cutting for Stone

AND SUDDENLY POPSY WAS THERE, his head perilously close to the operative lights. He had a deeply furrowed face, kind blue eyes, the pupils rimmed with gray but retaining a curious, little-boy quality. His mask hung just under his nose, wire-brush hairs poking out from his nostrils. He held out his gloved hand for the knife. Sister Ruth hesitated, glancing at me before putting it in his palm.

Popsy made a sound in his throat. The scalpel quivered in his fingers. Sister Ruth nudged me. Before I could do anything, Popsy made his incision. It was bold. Very bold. I dabbed and I clamped tiny bleeding vessels, and when Popsy didn't move to tie them off, I did. Popsy handled the forceps to pick up the peritoneum. He couldn't get purchase on the tissue.

For good reason. In one spot his skin incision had cut through fascia and peritoneum. Liquid matter, looking suspiciously like bowel content, welled into the wound. Ronaldo peered over the anesthesia screen and his eyebrows disappeared under his surgical cap.

Popsy tried again with the forceps, but the instrument slipped from his fingers and clattered to the floor. He brought his hand up, minus the forceps. “I touched the side of the table …” He was looking at me, as if I might dispute his account. “I've contaminated myself.”

“I think you did,” Sister Ruth said hastily when she saw that I was tongue-tied.

“You did, sir,” Ronaldo said.

But Popsy still looked at me.

“Yes, sir,” I stammered.

“Carry on,” he said. He shuffled out of the room.

“POPSY, WHAT DID YOU DO?” Deepak muttered under his mask as he brought out the injured loop of small intestine. I stayed on the left side of the table. “They say there are old surgeons, and bold surgeons, but no old-bold surgeons. But whoever said that never met Popsy. Fortunately it's a small-bowel tear and we can just stitch it over.”

“I tried to—” I stammered.

“We have a bigger problem,” Deepak said. He pointed to what looked like a small barnacle on the surface of the bowel. Once I saw that first one, I saw them everywhere, even on the apron of fat that covered the bowel. The liver was misshapen, with three ominous bumps within making it look like a hippo's head.

“Poor man,” Deepak said. “Feel his stomach.” The stomach wall was rock hard. “Marion, you biopsied the ulcer when you ‘scoped him, right?”

“Yes. The report said benign,” I said.

“But this was a large ulcer on the greater curvature?”

“Yes.”

“And which ulcers in the stomach are more likely to be malignant?”

“Those on the greater curvature.”

“So your suspicion for malignancy was high, right? Did you look at the slides with the pathologist?”

“No, sir,” I said, dropping my eyes.

“I see. You trusted the pathologist to read the biopsies for you?”

I said nothing.

Deepak's voice wasn't raised. He could have been talking about the weather. Dr. Ronaldo couldn't hear him.

Deepak explored the pelvis, swept with his fingers to those places we could not see. Finally he said, almost under his breath, “Marion, when it's your patient and you are basing your surgery on a biopsy, be sure to look at the slides with the pathologist. Particularly if the result isn't what you expect. Don't go by the report.”

I felt terrible for Mr. Walters. I could have spared him this operation, spared him Popsy In retrospect, Mr. Walters s liver function tests were marginally off, and that should have been a clue.

Deepak repaired the hole in the bowel. Fortunately, there was just one. He oversewed the bleeding ulcer in the stomach; it would in time bleed again. We washed out the abdominal cavity with several liters of saline, pouring it in, then suctioning it out.

“Okay, come to this side, Marion. I want you to close.”

I worked steadily under his eagle eye.

“Stop,” Deepak said. He cut away the knot I had tied. “I know you have probably done a lot of surgery in Africa. But practice doesn't make perfect if you repeat a bad practice. Let me ask you something, Marion … Do you want to be a good surgeon?”

I nodded.

“The answer isn't an automatic yes. Ask Sister Ruth. In my time here, I've asked that question of a few others.” I could feel my ears turning red. “They say yes, but some should have said no. They didn't know themselves. You see, you can be a bad surgeon, and as a rule you will make more money. Marion, I must ask you again, do you really want to be a good surgeon?”

I looked up.

“I guess I should ask what does it involve?”

“Good. You should ask. To be a good surgeon, you need to commit to being a good surgeon. It's as simple as that. You need to be meticulous in the small things, not just in the operating room, but outside. A good surgeon would want to redo this knot. You're going to tie thousands of knots in your lifetime. If you tie each one as well as humanly possible, you'll experience fewer complications. I want to see even tension on both limbs. The last thing you want is for Mr. Walters to have a burst abdomen when he gets post-op bloating. That knot, done well, may allow him to go home and get things in order. Done poorly it could keep him in hospital with one complication after another till he dies. The big things in surgery depend on the little things.”

That afternoon we sat in the cramped office of Dr. Ramuna, the pathologist. She found cancer in the edge of one of the six biopsies I had taken days ago. A stern lady, Dr. Ramuna had a way of pursing her lips that reminded me of Hema. She was unfazed about having missed the cancer the first time. She pointed to the teetering stack of cardboard slide trays by her microscope—biopsies waiting to be read. “I'm doing the work of four pathologists, but I'm only here half-time. Our Lady can't afford more that that. But they don't give me half the work. I can't spend enough time with each specimen. Of course I missed it! No one comes down here to go over slides with me, other than you, Deepak. They call. ‘Have you read this specimen yet? Have you read that specimen?’ If it matters to you, come down, I say. Give me good clinical information and I can do a better job of interpreting what I see.”

I KEPT VIGIL over Mr. Walters. We had passed a tube through his nose into his stomach and connected it to wall suction, to keep his gut empty for the next few days. He was miserable with the tube and hardly spoke.

On the third post-op day I took out the nasogastric tube. He sat up, smiled for the first time, taking a deep breath through his nose.

“That tube is the Devil's own instrument. If you gave me all of Haile Selassie's riches, I'd still say no to that tube.”

I took my own deep breath. I sat on the edge of his bed. I held his hand. “Mr. Walters, I'm afraid I have some bad news. We found something unexpected in your belly.” This was the first time in America that I had to give someone news of a fatal illness, but it felt like the first time ever. It was as if in Ethiopia, and even in Nairobi, people assumed that all illness—even a trivial or imagined one—was fatal; they expected death. The news to convey in Africa was that you'd kept death at bay. Those things that you couldn't do, and those diseases you couldn't reverse, were left unspoken. It was understood. I don't recall an equivalent word for “prognosis” in Amharic, and I'd never tried to speak to a patient about five-year survival or anything like that. In America, my initial impression was that death or the possibility of it always seemed to come as a surprise, as if we took it for granted that we were immortal, and that death was just an option.

Mr. Walters s expression went from joy over the tube being out, to shock, and finally sadness. A single tear trickled down his cheek. My gaze turned foggy. My beeper went off, but I ignored it.

I don't think you can be a physician and not see yourself reflected in your patient's illness. How would I deal with the kind of news I'd given Mr. Walters?