Harvesting the Heart

Nicholas

Nicholas was having a hell of a week. One of his patients had died on the table during a gallbladder removal. He’d had to tell a thirty-six-year-old woman that the tumor in her breast was malignant. Today his surgical rotation had changed; he was back in cardiothoracic, which meant a whole new list of patients and treatments. He’d been at the hospital since five in the morning and had missed lunch because of afternoon conferences; he still hadn’t written up notes on his rounds; and if all that wasn’t enough of a bitch, he was the resident on call and would be for thirty- six hours.

He’d been summoned to the emergency room with one of his interns-a third-year Harvard student named Gary who was green around the gills and reminded Nicholas nothing of himself. Gary had cleaned and quickly prepped the patient, a forty-year-old woman with superficial head and face wounds that were bleeding profusely. She had been assaulted, most likely by her husband. Nicholas let Gary continue, supervising his actions, his touches. As Gary sewed up the lacerations on her face, the patient began to scream. “Fuck you,” she yelled. “Don’t you touch my face.” Gary’s hands began to shake, and finally Nicholas swore under his breath and told Gary to get the hell out. He finished the job himself, as the woman cursed him out from beneath the sterile drapes. “Goddamned fucking pig asshole,” she shouted. “Get the fuck away from me.”

Nicholas found Gary sitting on a stained cube sofa in one of Mass General’s emergency room lounges. He’d drawn his knees up and was doubled over like a fetus. When he saw Nicholas coming toward him, he jumped to his feet, and Nicholas sighed. Gary was terrified of Nicholas; of doing anything wrong; of, really, being the surgeon he hoped to be. “I’m sorry,” he murmured. “I shouldn’t have let her get to me.”

“No,” Nicholas said evenly, “you shouldn’t have.” He thought of telling Gary everything that had gone wrong for himself today. See, he’d say, all that, and I’m still standing up, doing my job. Sometimes you just have to keep pushing, he’d say. But in the end he did not say anything to his intern. Gary would figure it out eventually, and Nicholas didn’t really want to recount his own failures to a subordinate. He turned away from Gary, a dismissal, feeling every bit the arrogant son of a bitch that he was reputed to be.

For years now, Nicholas had not gauged time by its usual measures. Months and days meant little; hours were things you logged onto a patient’s fact sheet. He saw his life passing in blocks, in places where he spent his days and in medical specialties where he filled his mind with details. At first, at Harvard, he’d counted off thmerhe spyoue semesters by their courses: histology, neurophysiology, anatomy, pathology. His last two years of rotations had run together, experiences blending at the edges. Sometimes he’d be remembering an orthopedic patient at the Brigham, but he’d picture the decor of the orthopedic floor at Massachusetts General. He’d started his rotations with internal medicine; then came a month of psychiatry, eight weeks of general surgery, a month of radiology, twelve weeks of obstetrics/gynecology and pediatrics, and so on. He had forgotten about seasons for a while, shuttling from discipline to discipline and hospital to hospital like a foster child.

He’d decided on cardiac surgery-a long haul. The match had placed him at his first-choice hospital, Mass General. It was a large place, impersonal and disorganized and unfriendly. In cardiothoracic surgery, the attendings were a brilliant group of men and women. They were opinionated and impulsive; they wore pristine white lab coats over their cool, efficient demeanors. Nicholas loved it. Even during his postgraduate year one, he’d observe the easy motions of general surgery, waiting to be rotated back to the cardiac unit, where he’d marvel at Alistair Fogerty performing open-heart operations. Nicholas would stand for six hours at a time, listening to the thin ring of metal instruments on trays and the rustle of his own breath against his blue mask, watching life being put on hold and then recalled.

“Nicholas.” At the sound of his name, he turned to see Kim Westin, a pretty woman who’d been in his graduating class and was now in her third year of residency in internal medicine. “How’s it going?” She came closer and squeezed his arm, propelling him down the hall in the direction he’d been walking.

“Hey,” Nicholas said. “You don’t have anything to eat, do you?”

Kim shook her head. “No, and I’ve got to run up to five, but I wanted to see you. Serena’s back.”

Serena was a patient they’d shared during their final year of rotations at Harvard. She was thirty-nine and she was black and she had AIDS-which, four years earlier, had still been rare. She’d come and gone in the hospital over the years, but Kim, in internal medicine, had more contact with her than Nicholas. Nicholas did not ask Kim what Serena’s status was. “I’ll go by,” he said. “What’s the room?”

After Kim had disappeared, Nicholas went upstairs to round his new cardiac patients. That was the hardest part about being a resident in general surgery-the constant changes from department to department. Nicholas had swung through urology, neurosurgery, emergency room, anesthesia. He’d done a stint in transplants, and one in orthopedics, and one in plastic surgery and burns. Still, coming back to cardiac was better than the others; cardiac surgery felt like home. And indeed Nicholas had been rotated through cardiothoracic more than was normal for a third-year, because he had made it clear to Alistair Fogerty that one day he was going to have his job.

Fogerty was exactly what Nicholas had pictured a cardiac surgeon to be like: tall, fit, in his late fifties, with piercing blue eyes and a handshake that could cripple. He was a hospital “untouchable,” his reputation having evolved into a surgical gold standard. There had once been a scandal about him-something involving a candy striper-but the rumors were squelched and there had been no divorce and that was that.

Fogerty had been Nicholas’s attending physician during his internship, and one day last year Nicholas had gone to him in his office and told him his plans. “Listen,” he’d said, even though his throat had been dry and his palms had been quivering. “I want to cut through the bullshit, Alistair. You know and I know I’m the best surgical resident you’ve got here, and I want to specialize in cardiothoracic. I know what I can do for you and for the hospital. I want to know what you can do for me.”

For a long moment, Alistair Fogerty had sat on the edge of his mahogany desk, riffling through a patient’s file. When he finally lifted his head, his eyes were dark and angry, but in no way surprised. “You, Doctor Prescott,” he said, “have got bigger balls than even me.”

Alistair Fogerty had got to be director of cardiac surgery by sticking his neck out, taking chances, and courting Fate so that it seemed to stay on his side. When he’d begun doing transplants, the newspapers dubbed him “The Miracle Maker.” He was calculating, stubborn, and usually right. He liked Nicholas Prescott a hell of a lot.

And so even when Nicholas was rounding his regular patients in general surgery, and working under other attendings in other disciplines, he still found time to meet with Fogerty. When he had the chance, he rounded Fogerty’s patients, did the quick daily pre- and postoperative exams, moved patients in and out of surgical ICU-in short, acted like a cardiothoracic fellow, a seventh-year resident. And in return, Fogerty had him in cardiac surgery more often than not and was grooming him to be the best there was-after Fogerty himself.

Nicholas moved quietly into the recovery room, where Fogerty’s latest patient was resting. He read the vitals: here was a sixty-two-year-old man who had had aortic stenosis-the valve leading from the end of his ventricle to the aorta had been scarred down. Nicholas could have easily diagnosed this case from the symptoms: congestive heart failure, syncope, angina. He surveyed the clean white gauze over the patient’s chest, the gelatinous orange antiseptic that still coated the skin. Fogerty’s work, as always, would be perfect: the native valve removed and a pig valve sewn into its place. Nicholas checked the patient’s pulse, tugged the sheet up, and sat down beside him for a moment.

It was cold in recovery. Nicholas crossed his arms and rubbed his hands up and down, wondering how the patient, naked, could be faring. But there, the pink circles at his fingertips and his toes proved that the heart, marvelous muscle, was still working.

It was merely fortuitous that he saw it then, the heart breaking down. He had been watching the steady rise and fall, the classic heartbeat pattern of the monitor, when everything went wrong. The steady blip- blip-blip of the machines accelerated, and Nicholas checked to see a sinusoidal pattern, the heart racing at nearly one hundred beats per minute. For a quick second, Nicholas held his hands over the patient like a faith healer. It was an arrhythmia-ventricular fibrillation. Nicholas had seen cases of it before, when a heart was exposed in the chest: beating like a bag of worms, swollen and writhing, not pumping blood at all. “Code!” he yelled over his shoulder, seeing the nurses at the nearby station spring into motion. The patient’s heart had been traumatized, operated on, but Nicholas had little choeck‘d little ice. In a matter of minutes, the man would be dead. Where was Fogerty?

Almost immediately, recovery was filled with at least twenty people-anesthesiologists, surgeons, interns, and nurses. Nicholas applied wet gel pads to the patient’s raw chest, then put the defibrillator paddles to the skin. The body jumped with the shock, but the heart did not correct itself. Nicholas nodded to a nurse, who adjusted the