It was well past midnight when a ring awakened Krebs’ from a dreamless sleep. The old surgeon groped in the dark for the phone. His hand found the receiver, and he pressed its cold plastic to his ear.
“Dr. Krebs?” the voice said.
“Yeah. Who’s this?”
“It’s Vandergraff. I’m in the ER. I’ve got a guy with a leaking aneurysm.”
Fuck, Krebs thought.
“You sure of the diagnosis?”
“The CAT scan confirms it. There’s no doubt.”
“What kind of shape is he in?”
“Bad. Can’t keep his pressure up. I doubt if he’ll survive.”
“Get his ass to the OR,” Krebs said. “I’m on my way.”
“We’ll be waiting for you.”
There was an empty click in the receiver. Krebs hung up and for a moment lay staring into the dark. With stinging eyes, he waited for the fog of sleep to clear. He pictured the man on an operating table. A pool of blood in his belly. For an instant, he wished the patient dead so he could escape back into the warmth and sweetness of sleep. He pried himself from the bed and made way to the bathroom. His knees were stiff and the the joints of his fingers ached. He splashed cold water on his face and ran a brush through a nest of gray hair. He pulled on a fresh set of scrubs that he kept at home for occasions like this
Krebs hurried through the dark to his car. He drove his Mercedes diesel with 100,000 miles on the odometer toward the hospital through ghost-ridden streets. The sky was black without a moon or stars. The road in front of him was empty. A light rain was falling. He could see the drops slanting through the beams of his head lights. He felt as if he were the only person on earth. The life of a surgeon seemed unbearably hard, a young man’s game. He wondered why the hell he was still playing it. At the same time, he knew the answer. A surgeon was who he was. He was born to operate. Since his wife of 40 years died, there was nothing else left. To operate was all he wanted to do.
When Krebs saw the hospital looming before him with it stacks spewing smoke into the night, adrenaline seeped into his circulation, and his pulse sped. He thought of the last aortic aneurysm he operated on. It was two months ago. Vandergraff was the resident on his service and had assisted him with the surgery. The bulge in the aorta was small and hadn’t ruptured. “A piece of cake” he would have called the surgery in his prime. But the operation had gone badly. The suture line where he anastomosed the graft to the aorta had bled in the recovery room. Krebs rushed the patient back to surgery, but it was too late. The patient’s blood wouldn’t clot in spite of transfusions of fresh frozen plasma and platelets, and he died on the table. After the surgery, Krebs was in the bathroom of the surgeon’s locker room, grieving for the patient and himself. He overhead Vandergraff talking to a first year resident about the case.
“He’s over the hill,” Vandergraff had said.
Krebs was ashamed of what had happened. It was as if the very essence of who he was was in doubt. Every time he thought of the case he felt miserable. Now the remembrance of the man’s death brought a cold hollowness to his chest.
Krebs stepped into the operating room. White light. White tile walls. A gleaming terrazzo floor. Everything was clean and cold, white and hard as bleached bone. In green gowns and latex gloves, his surgical team was preparing for him. Sue, the circulating RN, lathered the patient’s belly with an amber solution of Betadine soap. She was young and leggy with mascara-crusted eyelashes and chestnut curls tucked under her surgical cap. Krebs saw the sway of slim hips beneath her gown. He thought in his younger days he would have been tempted and so would she.
Vandergraff stood by a lighted view box on the the wall that displayed a CT scan of of the patient’s abdomen. Over his hands a sterile towel was draped. The young resident was lean with straw-hair with doubting metallic blues eyes above his mask. Even before he overheard Vandergraff’s “over the hill” accusation Krebs didn’t care for him. He thought the rookie was cocky. He didn’t like the way he treated the nurses in the operating room. Vandergraff was smart, but Krebs believed that becoming a good surgeon involved more than mastering operating techniques and the science of medicine. It required a sensitivity and compassion that he didn’t see in Vandergraff.
Monique, a large bosomed scrub nurse from Trinidad, arranged instruments in tidy rows on a Mayo stand — brushed steel hemostats, German-made needle drivers, forceps and towel clips, a thousand dollar pair of Metzenbaum scissors. To Krebs the expensive hardware had become commonplace like tools to a laborer.
“Good evening, Dr. K,” Monique said. Her words were nicely tinseled with a British accent.
“Let’s hope so,” Krebs said.
He was grateful Monique was on the case. She had scrubbed for him for years and knew his routine nearly as well as he did. She anticipated what he needed and stayed a step ahead of him. His operations always went smoother when she was passing the instruments and his mood reflected it.
At the head of the operating table Bill Riley, the anesthesiologist, stood, pumping blood into the patient’s IV line with a rubber-gloved hand. He was a big likable Irishman with a ruddy face, a big belly, and orange eyebrows. Pasted to his gas machine was a sticker with “VIGILANCE” in red letters. On the stool behind him was a copy of the Wall Street Journal. He stood at attention and saluted Krebs.
“At ease, Private Riley,” Krebs said.
In the operating room, all of Krebs’ senses were sharpened like a hunter in the bush. He didn’t like surprises. He saw everything. He saw the monofilament sutures on the Mayo stand. He saw the aortic grafts made of corrugated Dacron. He could smell the hot dry odor of instruments fresh out of the autoclave. He could hear the green bleeps of the cardiac monitor. In the blaze of the operating light, he saw the patient anesthetized on the table. Just as Krebs had pictured him over the phone, he was fat and grizzled with a scruffy beard and white hair that curled over his ears. His eyebrows were thick and wild, his toenails yellow and gnarled. A catheter in his long flaccid penis drained dark urine into a plastic bag. Krebs wondered who the man was, what family he had, what he had done with his life.
Krebs moved to Vandergraff’s side. The young resident towered over the short and stoop-shouldered Krebs.
“So, doctor,” Krebs said keeping his eyes on the view box. “Tell me about the patient?”
“He’s sixty-four,” Vandergraff said. “Going on a hundred. He’s a diabetic with emphysema and prostate cancer. He’s on Digoxin, Lasix, Lipitor, Lupron, and Glucagon. He’s high risk for a hair cut.”
“Sixty-four with piss poor protoplasm,” Krebs said. He turned his head and seared the resident with his gaze. “Over the hill some might say.”
Krebs studied the grainy images of the swollen aorta. He noted the interruption in the ring of calcium in the wall of the aneurysm and the puddle of white contrast material that has leaked through it. He estimated the diameter of the aneurysm to a large 12 to 14 centimeters. He was relieved to see that the dilatation started below the renal arteries.
“So, Dr. Vandergraff,” Krebs said. “Based on your vast experience with abdominal aortic aneurysms, what do you think of the case?”
“We’ve got a tiger by the tail,” Vandergraff said.
“No, son,” Krebs said. “Not a tiger. A lion. A big one.”
Recently Krebs had been rereading Faulkner and Hemingway. He was thinking of Hemingway’s “The Short Happy Life of Francis Macomber” and the Somali proverb that said a brave man is always frightened three times by a lion, when he sees his track, when he hears him roar, and when he first confronts him.
Krebs swung his gaze from the view box back to the patient on the operating table. He was blue and mottled from the umbilicus down as if he were wearing a pair of tie-died pants. It was an ominous sign that meant the circulation to the lower half of his body was inadequate. The mountain of the old man’s belly caused a voice inside Krebs to groan. He knew everything about the surgery was going to be a bitch. There was a time not too long ago when Krebs considered surgeons who didn’t possess his skills in the OR inferior to him. In those days, he believed he could rip an aorta in two with his hands and repair it before the patient bled to death. Now he wondered if he had the fortitude and technique to do the job. A sense of dread crowded in on him. He looked up at the cardiac monitor above Riley’s head. A hieroglyph of blips scrolled across the screen.
“How’s the guy doing?” he asked.
“He aint no rose,” Riley said from his seat behind the ether screen. “But he’s got a pressure. At least for the time being.”
“How much blood you got?”
“Four units typed and crossed,” Riley said. “We’re working on more.”
Sue finished her prep and tossed a sponge into a metal bucket. Monique stepped up to the operating table and handed Vandergraff folded blue towels one at time. The resident began draping the belly.
“No. No,” Krebs said sharply. “Don’t fence me in. Go wide with those drapes. He’s a big boy. We’re going need all the room we can get.” He turned and started toward the door. “I’m going to scrub, then we’ll get this show on the road.”
Krebs stood at the sink in the corridor and scrubbed his hands with a stiff brush and cold water. In his mind, he rehearsed the techniques and pitfalls of aneurysm repair. He warned himself to stay away from the ureters. He questioned whether he would he have to open the chest to get control of the aorta. Would he have to use a straight graft or a Y-graft? Krebs reminded himself to release the aortic clamp slowly to avoid a drop in blood pressure that could lead to a myocardial infarction or stroke.
When he finished his scrub, he held out his hands. He turned them slowly and studied them. The skin on the back was creased and wrinkled, spotted and bruised. In the anatomical snuffbox between his thumb and index finger there was a raised white scar where a squamous carcinoma had been removed. His knuckles were deformed with the nodules of osteoarthritis. His fingers vibrated with a fine tremor. Krebs thought his hands told a story. It was about someone who was aging and had lost his power. It made him sad.
Krebs backed through the door into the operating room with water dripping from his elbows. Monique handed him a towel and he dried from finger tips to elbows. The scrub nurse held out a green cloth gown, and Krebs plunged his arms into its sleeves. While Sue tied him up, Monique gloved him. He could smell Sue’s perfume, the scent of sandalwood.
“Sue City Sue,” Krebs said. “Sweetest girl I ever knew.”
Sue patted his butt. Krebs smiled under his mask, thinking he didn’t have much of an ass anymore.
“Oh, Jesus,” Riley grumbled with a twinkle in his eyes. “It’s a love-in.”
Krebs bellied up to the table beside Monique and across from Vandergraff. He rested his hands on the big abdomen. He could feel the pulsations of the aneurysm banging like an angry fist on a door. He held out his open hand and Monique slapped the handle of a scalpel into it. He liked the way it stung his palm. He felt a surge of power. For a moment, Krebs peered over the ether screen at the man’s pale face. Riley was patching his eyes with gauze to protect them from corneal abrasions. With each puff of the ventilator, the plastic tube in the old man’s trachea frosted like breath on a cool window and saliva gurgled in his toothless mouth.
“God help you, fellow,” Krebs prayed silently to a deity he wasn’t sure he believed in. “God help me.”
He swung his gaze away from the man’s face to his belly and Krebs’ mind detached itself from the patient’s persona. With a single swipe of the knife, Krebs cut him from sternum to pubis. A fatty red gash appeared. Vandergraff jabbed at oozing capillaries under the skin with the cautery. A blue spark sizzled at the tip of his instrument and smoke wafted from the wound. Krebs frowned beneath his mask. He didn’t like the young residents surgical technique, his herky-jerky moves. Krebs believed an operation should have rhythm and grace like a dance.
“Easy there,” he said. Krebs told himself to be patient with the young surgeon even though he didn’t like him. He knew that performing surgery wasn’t like riding a bike, you didn’t get it all at once. “Be gentle. Be smooth.”
Krebs opened the membranous lining of the abdomen cautiously with a pair of Mayo scissors taking care to not nick underlying structures. The filmy curtain of peritoneum parted, and he looked down into the abdominal cavity. Although he had entered this canyon of anatomy thousands of times, he still found it a place of mystery and the organs it contained strangely beautiful. “A sweet work of nature,” he remembered that Shakespeare had written. The man’s liver, cobbled from alcohol, crouched beneath the dome of the diaphragm. His omental fat was an apron of glistening gold globules. The small intestines gleamed and writhed in the light like a nest of snakes. Krebs dove his hand deep into their midst, felt warmth and wetness through his glove. His fingers found the big aneurysm, tense and beating as if it were an extra heart. Krebs took a deep breath and began packing away the intestines in a plastic bag that he covered with laparotomy sponges. Chitlins he called them. First, he gave Vandergraff two silver retractors to hold for exposure and to tie up his hands and keep him out of the way. Then he changed his mind and asked for a self retaining retractor so Vandergraff’s hands would be free when he need them.
Now that he could see it, Krebs studied the aneurysm, throbbing and tawny. He thought again of the lion hunting proverb’s three times of fright. He had seen the tracks. He had heard its the roar. Now was the confrontation. The size of his foe gave Krebs a cool, electric sensation.
“Carumba,” he muttered. “King of the beasts.”
His eyes found a blue hematoma in the tissues that surrounded the aorta where blood had leaked from the crack in aneurysm’s weakened wall. A clot had formed that tamponaded the hemorrhage and saved the old man’s life. Krebs wanted to get control of the aorta quickly before the clot had time to let go.
“Right angle,” he barked.
“Which one?” Monique asked.
“Give him the Mixter clamp,” Vandergraff said.
“Christ no,” Krebs said. “Something blunter.”
Monique passed him the instrument he wanted, and he began to dissect around the neck of the aneurysm. With the tip of the clamp, Krebs cautiously probed and spread dense and inflamed tissues. He had lost some of his dexterity but not his instincts. The going was tough, and he worked slowly. Frequently, he changed the direction of his dissection to try and find the path of least resistance around the aorta. Out of the operating room Krebs was an impatient man, but in the OR, he was immune to the passage of time. The renal vein was stretched precariously over the aorta and in his way. To damage it could be fatal.
“Don’t tear, you son of a bitch,” Krebs said silently as he nudged the big vein aside with his clamp.
A rash of sweat erupted on his forehead.
During the past couple of year Krebs had been playing not to lose in the operating room. Along with belief in himself, he had lost the fortitude to accept complications. He had become overly cautious when dissecting around vital structures and less radical when performing cancer operations. “First do no harm” had always been his credo. But when he was honest with himself, he knew that by trying to do no harm, he was in fact doing harm. Show some guts for a change, he told himself.
Krebs returned the right angle clamp to Monique and began dissecting behind the aorta with the index finger of his right hand. Blindly, painstakingly, he pushed and probed, wiggling the tip of his finger. The aortic pulse was savage. After a while, his hand began to cramp. But he kept working. Finally he found his thumb and index finger encircling the aorta. He let out a long sighing breath.
“Give me the Riley clamp,” he said to Monique. “The big ugly one?”
Krebs was trying to relax everyone including himself with a little humor.
“Oh, great,” Riley said. “It’s “Saturday Night Live.””
Monique slapped an aortic clamp into Krebs’ hand. The instrument was a DeBakey named for the great Texas cardiovascular surgeon who was a hero of Krebs along with William Carlos Williams, Jonas Salk, and Chekov. Most all of his heros were doctors. The DeBakey was a beautiful instrument, long and light with its handle gracefully curved like the neck of a heron. Krebs loved the clamp the way a fisherman loves his favorite rod. When he ratcheted its jaws down on the artery, he felt a crunch as it crushed the calcium in the wall of the vessel. He cringed, hoping he hadn’t loosened atheromatous debris that would embolize to the legs. But what was done had to be done. Letting the chips fall where they might, Krebs thought both literally and figuratively. He knew sewing in the calcified artery would be difficult. He remembered the patient that had bled to death. He prayed his sutures would hold.
Krebs took a scalpel from Monique and opened the aneurysm with a longitudinal incision in the big bulge. The artery was filled with clot and a soft ripe material that looked like limburger cheese. Krebs thought he could smell it. He wondered how something this rotten could exist inside a living human being. For an instant, Krebs was angry at the old man. He resented him and his bad habits, his smoking and the dietary indiscretions that had created this surgical ordeal and was keeping Krebs from sleep. Monique handed him a serving spoon that he used to scoop the cheesy gunk from inside the aneurysm and deposit in an emesis basin that Vandergraff held. Since his wife’s death, Krebs’ diet was unhealthy. He wondered what his own aorta looked like. He was relieved to see that a straight graft could be used rather than a Y-graft. It would cut down on operating time, and he could get the old boy off the table sooner.
Krebs took the tube of Dacron and soaked it in pool of blood to preclot it and cut down on blood loss.
“Why aren’t you using Gotex?” Vandergraff asked.
“Because I prefer Dacron,” Krebs said irritated. “Suck the puddle. Come on. Keep it dry.”
Krebs began to sew — graft to host, Dacron to tunica. From a across the table,Vandergraff followed the suture for him, grasping it between his thumb and index finger while Krebs reprimanded him for not keeping the right tension on the stitch. Krebs took big bites that he hoped wouldn’t tear out. The needle was dulled by the plaques of calcium it had to penetrate. He tipped his head so that his bifocals focused better. His back ached. His tremor frustrated him. He steadied the needle holder with his left hand when he took a stitch. The arm pits of his scrub suit were soaked. He worked without talking except for essential commands to Vandergraff like “sponge,” or “come on, doctor, suck.”
Krebs came to a difficult corner of the anastomosis. His angle was bad, and he couldn’t position his hand properly to take the stitch.
“I have a straight shot,” Vandergraff said.
He reached for the needle driver. Krebs pushed his hand away. He flipped the needle over in the jaws of the instrument and took the stitch back-handed.
“Nice, Mon,” Monique said in her crisp Caribbean accent.
“Old dog. New trick,” Krebs said.
He glanced up at Vandergraff. For an instant, their gazes locked then Vandergraff looked away.
“Old dog make it look easy,” Monique said.
“It is easy,” Riley quipped. On his stool, he was drinking a Coke through a straw that ran under his mask. “You could teach a monkey to do it.”
Like the one across the table from me, Krebs thought. He kept suturing. He was fighting to not lose his concentration. He was aware of the quick deep stabs of the ventilator’s breathes. The green sound of the monitors bleeps. He wanted the foolish banter to stop.
“Enough chatter,” he said.
When the anastomoses were complete, Krebs took a deep breath. He turned from the operating table to let Sue wipe sweat from his brow with a towel. He looked up at the clock on the wall. Two hours had passed without him realizing it.
“How’s he doing?” he asked Riley.
“Hanging in,” Riley said.
“When you think he’s ready,” Krebs said to Riley, “I’m going to release the clamp.”
“Let me fill up his tank,” Riley said.
He turned a valve on the IV line and a stream of saline poured into the patient’s vein. Krebs waited with his hands resting on the drapes. I’m nothing but a high priced plumber, he thought. But that’s okay. Plumbing is an honorable thing to do.
When the systolic pressure was up to eighty, Riley told him to try opening the aortic clamp. Krebs slowly released it while Riley counted out the systolic pressure.
“Seventy. Down to sixty,” Riley said.
Krebs clicked the clamp closed. He wondered if old guy’s heart had given up.
After a couple of minutes, Riley said, “Up to ninety. Try it again.”
Krebs opened the clamp very slowly and this time the pressure held. Krebs was relieved to see that there was minimal leak from his suture line. He stood for a few seconds, watching the tubular white conduit of Dacron pulsate, bringing blood and life to the man’s legs. The graft shown in the bright overhead light like a white banner. It seemed to have an inner radiance. Krebs was aware of the beat of his own heart. He thought of the man’s age, how far his legs had taken him, how tired they must be. His own legs felt heavy and tired.
Krebs took his time tidying up the belly. Cauterizing bleeders. Pleating the wall of the aneurysm over the graft with 3-0 Vicryl. Irrigating the wound copiously with saline. The operating room was a world all to itself where Krebs, shielded from memories, found satisfaction like no place else. He was in no hurry to leave it. When he was certain there was no bleeding and there was nothing else do, he announced he was ready to close. Monique and Sue counted the blood soaked sponges, and Sue announced that the count was correct.
“You must be pooped,” Vandergraff said. “Want me to close?”
“I don’t get tired,” Krebs said although he was. “But you can close.” He stepped back from the table. “Use retention sutures. I don’t want this guy coming apart.”
“I know the drill,” Vandergraff said. “I’ll do it your way as the song goes.”
Krebs stripped off his gown. He balled it up and tossed it toward a hamper. It went in like the set shots he made as high school basketball player in the 50’s. He considered it a good omen. He went to the foot of the table and raised the drapes. The man’s legs were cold and blue, but Krebs could feel weak pulses in the arteries of his ankles. Satisfied that his patient had circulation to his feet, Krebs moved to the head of the table. Riley patted his shoulder and handed him the chart.
“Good work, man,” he said.
“He going to make it?” Krebs asked.
“I don’t know. He’s rocky, but he’s got a chance. I’m going to keep him on a ventilator.”
Krebs nodded. He had reached an age when the possibility of death had lost most of its impact, but he didn’t want the patient to die on his watch.
Monique was placing dirty instruments in a stainless steel dish pan. Krebs noticed the aortic clamp. Something told him he should take it. It would make a nice memento to keep on his desk at home. He picked up the DeBakey. With his head down, he started toward the recovery room. At the door he stopped and looked back at the old man on the table. Riley removed the patches from his eyes and the patient became a person again. His face was very pale and gray. His chest rose rhythmically with the beat of the ventilator. Krebs felt one with him. He wondered what the man’s life would be like if he did survive. Had he done harm by prolonging the man’s suffering? Did he want to die? But the value of the man’s existence was not his to judge. It was not his right to choose to end it. Krebs was a keeper of life. Then it occurred to him that all he had ever done in the operating room was merely palliation because life was a terminal illness.
“Thank you all,” he said. He raised a hand to his team.
Krebs stepped from the operating room into the corridor. It was like leaving a hallowed place. Morning sun light bloomed in the windows to the east. A nurse and an orderly wheeled a gurney that carried the first case of the day. Their green gowns rippled like sails gathering wind. The patient was a frightened child with a fractured femur. Krebs thought that the little boy was about the same age as his grandson whom he should get to know. The tears in the child’s eyes, his innocence, gave him a pang. He smiled down at him in a reassuring way. Krebs’ knees were sore from standing so long, and he hobbled on to the recover room. He sprawled onto a chair in the dictating booth. For a moment, he thought of all the years he had practiced surgery and how many abdominal aortic aneurysms he had repaired. He did the math in his head and decided it was close to 300.
That’s a lot, Krebs thought. Man, time went by fast …. and there is no turning it back.
Rosemary, a veteran RN with remnants of a good figure, dyed ginger hair, and a new titanium hip, brought Krebs a cup of hot coffee and the morning newspaper. She called him “Special K.” Rosemary had worked around the OR as long as Krebs had. She’d been through the wars with him. Krebs thanked her. He told her they were a couple of old dogs but she was still looking damned good.
“Best in show?” she said posing with her hands on her hips.
“You bet,” he said.
Krebs sipped the coffee savoring its dark flavor. He started to write the post operative orders: Morphine for pain, vital signs q 15 minutes until stable then every hour. He couldn’t remember the dose of the new cephalosporin antibiotic everyone was using. He’d better let Vandergraff write the orders. He closed the chart. He decided to drink his coffee and read the paper until he was sure his patient was stable. Then he would talk to the family.
Krebs picked up the aortic clamp. For a while he sat, clicking the jaws open and closed and thinking of possibilities, new things he might like to try, places he wanted to see. He liked the way the instrument felt in his hand. Suddenly, he felt totally spent. He let out a sigh of exhaustion. He tipped back in his chair. Krebs closed his eyes and waited for his patient.