Every Good Morning

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‘We are as much as we see.”  Thoreau’s Journals

I am beginning to look for another way of life, maybe another job, but most of all another way to see. Everyone knows that a job is almost never just a job but a whole network of relationships, routines and duties and new skills to learn and therefore the entranceway into another kind of life. I am almost 59, and I want another kind of life. I want new skills. I want more life. I want to learn to see in other dimensions.

Once I thought I might like to move to Hohenwald, Tennessee and work in the Elephant Sanctuary there (http://www.elephants.com/). Something about walking those hills and hollows and tending to those great creatures appeals to both my heart and imagination. Conceive of this:  every day you would look into the eyes of such intelligent, otherworldly and powerful beings.

If I had not been a teacher, I would have wanted to be a police officer or attend West Point and make a career in the army or become a surgeon: follow my father, follow my love of history, follow my curiosity about the body — follow occupations that all do a trade in intensity.

About 16 years ago I once saw a heart surgery at a great hospital*. A friend who worked there smoothed my way. Dressed in blue scrubs and a mask, I looked like everyone else, except that no one else was standing on two plastic milk containers six feet from the table, looking down on the operation as if he were a ghost. No one spoke to me.

When I entered the operating theater, I stepped into a large space filled with an indirect greenish light, 7 or 8 gowned scrub nurses, technicians, and 2 resident surgeons sitting in the corner wrapped in white sheets. In the very center on a solid metal and leather contraption lay the naked, splayed body of an 80 year old man. His eyes were taped shut. He wore his white hair long, swept back. He slept on pads of leather covered heating coils. Standing over his face, a tall, young anesthesiologist tried to find a vein right below the clavicle into which he could insert an IV shunt. The patient, Harry**, had smoked for 65 years. His veins were hard with age and tar. The anxious doc slipped over a vein, blood spurted and dripped, he cursed, and he tried the other side. Another young man worked on James’s left hand, searching, probing for a good vein, blood washing over the old man’s fingers and pooling on the tile.

The surgeon in charge walked in looking concerned. Jackson Michael* was 36, a graduate of Harvard, handsome in an offhand, casual way, and at the moment angry with the on-call cardiologist of the evening before who had missed or had not bothered to read the x-rays of Harry’s chest. There was a nodule on one of his lungs. Jackson wanted to talk to him, but he had left. Harry had been under anesthesia for an hour, he was 80, he was in the midst of being prepped, and the hole in his aortic valve would still be there no matter what, so Jackson, looking annoyed, gave the final go ahead and left.

At the end of the operating table a scrub nurse stood on four metal stools, each designed to fit into the other. She arranged row upon row of dully silver surgical instruments on a dark, velvet-looking spread which set on a scaffold-like structure attached to the table. Each of the cardiac surgeons had a “book” which detailed how each wanted his or her instruments arranged.

Next to her another nurse ministered to Harry. She took his penis in one hand and clear plastic tubing in the other. She had just thoroughly slathered the tubing in K-Y jelly. She threaded the tubing into his penis about the same way a plumber inserts a snake into a drain — without emotion, intent on feeling for obstructions, delicately but firmly. At the head of the table the young anesthesiologist was squeezing a tube of K-Y jelly down Harry’s throat. He poured a clear plastic tube down his throat, struck bottom, threw a switch and mucus crept up the tube from the belly. He followed this by angling lengthy rubber tubing down his throat; it was attached to some kind of tentacled sensing device which looked like an evolved form of the fetal creature from ALIEN.

There was a clear efficiency about their work, a comfortable repetition of impersonal but never careless or brusque tasks. Harry was never treated with tenderness, but he was never humiliated.

Machines hummed quietly. Two more technicians entered with an echo-cardiogram machine. They coated his chest with gel and skated the sensor across it. His beating heart, cloaked in shadows, appeared on the video screen. Jackson again, still in whites, stared intensely at it, and spoke quietly to the nurses and gathered residents. Then he again slipped out.

One nurse sponged Harry from his chin to his feet with a mixture of iodine and soap. His knees were bent outward so that, if necessary, a vein could be taken from one of his legs for a graft. She coated him twice, blotting him dry each time with a sterile wrapping. A blue cover was drawn over him, up to his chin. It had a clear, plastic window which showed his chest. A metal tray was hooked onto the table over his head. The surgeons leaned on this during the operation. IV’s were connected, and anesthesia pumped into him. Jackson walked into the room fully gowned and gloved. A Filipino resident named John and a Pakistani resident waited for his signal. Derrick took another look at the x-rays, at the monitor which registered heart rate, blood pressure and blood gases, at the monitor which registered dosages and types of anesthesia. “Let’s go,” he said, and John slipped into place with a scalpel and opened a thin line down the center of the clear covering and the center of Harry’s chest. Blood spread from the edges of the cut and the Pakistani, Ali, took something which looked like a turkey-baster in his right hand and sucked up the blood. It recycled through a Profusion Machine, a heart-lung machine, which squatted behind Jackson and whose top looked like a calliope. A dozen plastic tubes led from this and scattered under the table to some central device which gathered and began to filter Harry’s blood. The technician on this machine, in response to the softly spoken instructions of Jackson, twirled gauges, clipped and unclipped tubes, hit switches for pumps.

Jackson picked up a narrow, yellow device that resembled a soldering iron with the head of a scalpel. An electrical cord trailed from it. When he touched the line on the chest, steam rose from the wound he made. He cut deeply into the chest. The skin split easily and the cartilage and bone shown beneath the yellow of fat. Ali suctioned the split. The odorless air suddenly stank of burning flesh. The white of bone filled the small space on which they worked (about the size of an 8″ by 11″ piece of paper).

Handed a bone saw, a t-shaped machine the size of an electrical pencil sharpener, Jackson touched the chest, and pulled the trigger which set off a subdued buzzing. In a second or so he had sliced open the inch thick rib cage/sternum. Spreaders. He turned the handle and the ribs creaked as the chest yawned open to show a caul of filmy tissue. The electrical scalpel slipped through layer after layer of pink yellow gray stuff. The smell grew stronger. There, deeper within the cavity than one might have imagined, three or four inches deep, the heart appeared, thu-ump-pin-ing, thu-umpipin-ing, the size of a large fist, looking like a slithery red and yellow bag over a large fist, twitching furiously, moving in contortion after contortion.

Blood spurted two or three inches into the air. Jackson moved at the head of the cavity with a traditional scalpel. Ali leaned on the shelf over Harry’s face and nonchalantly suctioned. The heart-lung machine hummed. The monitors hummed. Next to me a scrub nurse collected bloody muslin sponges from a bucket next to the surgical PA, lay them out on the floor and counted aloud, “five… ten… fifteen…” up to thirty. The PA answered. The count was right. Jackson spoke to the anesthesiologist, to John, to the Profusion technician, to Ali and then the  thu-ump-pin-ing, thu-umpipin-ing, thu-ump-pin-ing stopped.

On the far operating room wall below the foot of the table a scoreboard-sized digital clock began ticking off the seconds since Harry’s heart had  stopped beating. Jackson folded his arms and softly spoke to John and Ali. He looked at the monitors. He reached into the wound and examined each hole in the valve. The scrub nurse began handing him tiny, fish-hook shaped needles. Very thin thread trailed from each. He manipulated a large tweezers in either hand, juggled the needle into place and began threading each needle, one after another after another after another through the valve of that silent heart. He tied one knot with each piece of thread and then attached each thread to a clothespin-like piece of metal. He stretched each clothespin out over the edge of the chest cavity and onto the blue covering where it began to create a circle around the wound and quickly began to resemble the beginnings of some complicated engineering project — the supports for a bridge, or the wiring of an open transformer.

His hands moved so quickly. They seemed to suddenly twist air again and again into the same intricate shapes. While Jackson worked, many hands dipped in and out and hovered over the wound, but Jackson’s dexterity and muscle memory, his absolute quiet command of the many hands and machines and tubes and instruments remained at the center of this harmony of computer and brain, metal and flesh, plastic and blood.

He now worked on each knot. He picked up a clothespin and with his fingers tied knot after knot. I lost count at ten. He did this with each piece of thread, a thread so delicate and thin it appeared only intermittently in a glance of light.

Harry’s heart had been stopped for over an hour and fifteen minutes.

All the clothespins were removed. The scrub nurse counted sponges again. Jackson started the heart. The flat line disappeared on the monitor. The heart seemed to leap an inch out of the cavity. It raced. Jackson asked for the electric paddles, and holding them steady on either side of the heart’s walls, counted seconds of electrical current, his eyes riveted on the heart rate on the black screen. The heart seemed to struggle in his hands, but blood was pumping through the arteries and veins and through the just repaired aorta. The knots held.

Quickly. A sponge was tucked next to the heart. For just a moment I thought I should remind someone that it was still there, that a mistake had been made, but I stayed a ghost. The electrical scalpel cauterized blood vessels in the sides of the rib cage/sternum which looked like a roast of lamb. Holes were punched in the skin under the rib cage and two plastic drains were laid across another large sponge which covered the whole chest cavity. The heart disappeared. Jackson stepped away from the table, checked all around him, spoke quietly (I was impressed with how courteously he had treated all 12 individuals who were involved here) and walked through the puff of air from the automatic door.

John and Ali used large curved needles and thread the thickness of weedwhacker nylon line, one after another, to drive through the edges of the rib cage and crisscross over Harry’s’ chest. When a dozen or so lay there, they grabbed each one and lifted Harry off the table and twisted and tightened, twisted and tightened. They grunted each time they lifted him. The ends were snipped. Needle and thread to close. They chattered happily as they sewed. Jackson, his hands in his pockets, in whites and mask, reappeared, checked the work, checked Harry’s vital signs.

My friend later told me that the most amazing thing she had ever seen was a patient with his chest cracked open on Monday and his smiling face opening up to her in intensive care on Tuesday. I don’t know what happened to Harry, only that when I last saw him, his chest was being closed.

*Immediately after watching the surgery, I set down detailed notes on what I had seen. I worked from those notes for this post.

**all of the names have been changed

© Mike Wall

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