A Surgeon’s Knot Read online

  Mrs. Simpson gently reclaimed her Bible. She slowly opened the worn pages to reveal a small object folded in a piece of paper. Taking it in her hands, she unwrapped the item with obvious care and love, revealing a simple gold wedding band. “Will you give this to him, Dr. Cooper? He has worn this on his ring finger for 53 years. I took it from him just before his surgery . . . I know he wants it. I don’t want him to be afraid!” She slowly lifted the precious ring from the package and placed it in Jackson’s outstretched hand.

  Mr. Simpson was cold and blue when Jackson entered his room to replace the ring. Housekeeping was scrubbing the walls; one man was on a ladder cleaning stains from the ceiling. Jackson approached the bed, looking at the patient. He was tall, distinguished man of 73 with a two-day scruff of a beard. Dressed now and cleaned as well as possible, the hospital-issued pajamas were stained with blood. The nurses had dressed the large gaping wound in his left neck, and he looked like he could be sleeping. Curiously, Jackson reached to his pocket for his stethoscope, anxiously wanting to make sure there was no heartbeat. He then remembered his race from the on-call room and vowed to retrieve the dropped instrument later. Mr. Simpson was very dead anyway, he reassured himself.

  Jackson looked around the small room. He moved to the window and opened the blinds to the early morning sun. There were some fresh lilies in a vase sitting on the nightstand, a get-well card addressed to Papa proudly standing by. Returning to the man, Jackson reached into his breast pocket and retrieved the package. What he thought was just a tissue turned out to be a page of personal stationery, flowers decorating the thoughtful bundle. In small, perfectly penned letters was the phrase: I love you, Herman. Wait for me, my dear. Yours forever, Sarah.

  Jackson placed the ring on the man’s stiffening finger.

  CHAPTER TWO

  Mr. Simpson’s attempted resuscitation and brutal death rudely awoke the hospital to the new day. The nursing staff, the physicians, and the hospital body were all conscious and not likely to go back to sleep. The event roused Dr. Jackson Cooper, perhaps never being able to sleep again. With time before his morning rounds, he migrated to the cafeteria, hoping for some stimulus in the form of coffee.

  The ancient stainless-steel commercial coffee urn stood as a testament to the new morning, making bubbling underwater sounds, the aroma passing for pleasurable. Jackson took a ceramic mug, filled it with a steaming brew, and grabbed a stale bagel and a pat of butter. He signed for the meal—after all, he was still technically on call and qualified for free food and drink.

  He sat at the table by the only exterior window, a wire-reinforced portal to the world, now covered with condensation. The sun was just peeking its face over the horizon, and a mindless pigeon tracked back and forth on the outside sill.

  Jackson’s brain felt numb, his body drained and weary. The coffee was a steaming example of bitterness, and the intern sipped it, feeling alone. He put his right foot up on the adjacent chair and leaned back, closing his eyes and wishing for sleep. Unsuccessful in that pursuit, his eye turned to his footwear. A stained boot with spots of Mr. Simpson’s dying blood met his eye, and he tried to clean the leather with a gauze pad moistened with his coffee. He forced his mind away from the gruesome death and family grief and reviewed the prior 24 hours.

  . . . . .

  It had been Jackson Cooper’s first day, and he had been so excited. Legally he was a doctor, the first day of his surgery internship. Now that the tragic events of the night were sadly over, his title would perhaps not excite him—maybe ever again.

  Jackson was a man just shy of six feet, with a scruff of curly brown hair and smoky blue eyes covered with heavy aviator glasses. He had worn a pink button-down shirt with a pink-and-green striped tie the prior morning, and he looked like a wrapped Easter gift. Corduroys worn over brown cowboy boots completed the picture.

  He had arrived early that day, as did everyone else. Shuffling into a full classroom, Jackson took a seat, realizing that he knew no one. Freshly scrubbed faces and expectant, wide-open eyes, filled the overcrowded room. A cute brunette woman with a highlighted streak decorating the front of her long hair was sitting to his left. She smiled at Jackson, her green eyes sparkling. Jackson nodded to her as he sat.

  Quickly, a man slipped in and stood at the front of the class. “I’m Dr. Fish from surgery,” he said in a hoarse monotone. His name matched his habitus: tall and sickly thin with large, protruding lips and heavy eyelids. “This is the 1981 surgery intern class?” He paused for a moment, wondering about their identity as he skeptically eyed the group. He turned to the blackboard and wrote in white chalk his name and “S-287” in large letters. “I hope you all have your assignments. Pick up your name badges here,” he said, turning and pointing to the room number on the blackboard with a long, twisted index finger. Dr. Fish shook his head. “I got nothing else to say to you,” he said with an air of displeasure. “Any questions?”

  It was an after-thought, Jackson was sure. Fish stood for a moment, scanning the classroom full of concerned individuals. He reached nervously to his left coat pocket. “The hospital is a rectangle.” Pointing to the right side he said this is the west-end, W one through three A on the North-side, B on the south-side. Same arrangement on the east end, E one through three A on the north, B on the south.

  Fish stood again scanning the class. A sly smile came over his thin puffy face. “Ya?” Was all he said as he tapped his toe rhythmically. “Ya, S-287 is over here.” He tapped a finger to the side of the rectangle, turned and eyed the group.

  It stunned the class to some extent, expecting some further direction, it obvious that they would get none. It was the first day; no babysitting occurring here. No one raised their hands. Dr. Fish looked at the group with his dodgy face. When there were no questions, he seemed relieved, turned and exited the room quickly. Fish pulled a pack of cigarettes out of his coat pocket as he left.

  Jackson turned to the woman next to him. She was of medium height and wearing a white coat over a red sheath dress. She was just getting up to leave.

  “Marlboro or Winston, do you think?” Jackson said, walking with the woman. She laughed and surprisingly pulled a package from her white coat pocket. She shook out a cigarette, offering it to Jackson.

  “Looked like a Winston man to me.”

  Declining the smoke, Jackson said, “Not yet, but thank you.” He moved along, giving way to the woman at the door. In the hallway, he struggled to keep up with her as they raced to their rounds. “I’m Jackson Cooper.”

  “Patrice Summers.”

  “Patrice, what a beautiful name! Do they name hurricanes after you?”

  “Wouldn’t surprise me! No one remembers my name, though. Sharice, Caprice, Patty, Patricia, Beatrice, Clarise, Sofia, Denise, Bernice; not so great when you realize that. Hey, I like your boots!” She turned at the next hallway, threw a sly glance and smile over her shoulder, then disappeared to his right.

  . . . . .

  With new interns, rounds were late the first day of the academic year. They moved the usual 6 a.m. to 6:15 a.m. on the surgery ward, West 3B. It was gray, damp, and somewhat cold that morning; the ward buzzed with morning activities. Jackson arrived at the nursing station and approached a white-coated group standing in front of a patient’s room door.

  “I’m Jackson Cooper,” he said, approaching the leader with a firm handshake.

  “James Wheeler. We’re just starting rounds.” The general surgery chief resident was a tall, ruddy man with closely cropped ginger hair and a red stubbly beard. Like everyone else in attendance, he wore a white coat thrown over a green surgical scrub suit, completed with blue plastic clogs. He reached for a bottle of Mylanta in his jacket pocket and took a long swig. “Thompson is presenting—you can do it tonight,” he said as he wiped his chalky lips.

  “Over here, guys.” Thompson Smith gathered the group near the first patient’s room. He was the junior resident, a roundish man with a small paunch, balding blonde hair, blue eyes, and wire-rimmed glasses. Dressed in scrubs, he had a plastic flower in his white coat lapel.

  “This is Jackson, Thompson.” Thompson eyed Jackson from head to toe, stopping for a moment at his boots. He grabbed a patient chart and handed it to Dr. Wheeler.

  The group gathered around Thompson as he presented the first patient to the group.

  “This is Mr. Washington. He’s a 63-year-old black male who is two days status post-cholecystectomy with common bile duct exploration.” Here he referred to a patient who had his gallbladder taken out two days before. During the surgery, the common bile duct, which drains bile from the gallbladder and liver, was opened and examined for larger stones. After this procedure, a T-tube was left to drain the bile. “He’s afebrile with stable vital signs. He has diabetes, so we have him on a regular insulin sliding scale, with blood sugars in the 180s.” The man had diabetes and required regular insulin injections to control his blood sugar.

  “His T-tube drained just 50 CCs in last 24 hours.” Thompson looked proud as the man was his case. The man’s bile duct was draining minimally. “Shall we take the tube out?”

  Dr. Wheeler said, with a touch of anger in his voice, “No, clamp the tube for 24 hours! Then remove it if the residual is small. Like I always do, Thompson!”

  Thompson looked embarrassed as he brushed back his thinning hair. The orders went on: oral liquids for the patient. Dr. Wheeler led the group into the patient’s room.

  There was obvious tension between the two surgeons, with the final decisions called by the chief, Dr. Wheeler. Thompson seemed to think, as he had done the case, they should follow his desires. Jackson knew of the controversy in gallbladder surgery, where exploration of the common duct occurred. The question was whether to leave a T-tube. A T-tube is a T-shaped conduit for the bile in the common bile duct to drain through. Controversy as to how to manage the removal of the tube after surgery existed. Jackson would have to investigate this issue later, and he made a mental note to read his green Textbook of Surgery by Sabiston if he ever got a moment.

  “Mr. Washington, how are you this morning?” The group stood around the foot of the man’s bed like birds of prey.

  The man reached into his bedside drawer and put in his false teeth. “Hi Doc. I’m hurting but doing okay. When do I get to eat?”

  “Maybe today, let’s see. Someone got ears?” Dr. Wheeler turned to the group, holding out his hand. A young medical student handed him his stethoscope. Dr. Wheeler moved to the patient’s bedside and gently had the man sit forward. Placing the stethoscope on his back, he said, “Now take a few deep breaths.” He then listened to the man’s upper abdomen. “Got a few tinkles there.” Here he referred to bowel sounds. Dr. Wheeler handed the scope back to the student. “Yeah, got some crackles in your lungs, Mr. Washington. Listen, you will get pneumonia. Work on this,” he said, lifting the plastic incentive spirometer. “Ten breaths every hour at least. Also, you’ve got to get walking. It will hurt, so I want you to take a pain shot. What do you have for him?”

  Dr. Wheeler looked at Thompson, who pulled out the patient’s plastic chart from their pushcart. “Demerol, 100 mg IM every three to four hours.” Here IM referred to an intramuscular injection.

  “Take a pain shot and then one hour later, when it is working, get the nurses to help you out of bed. Do this three times a day. First, just go to the door. Next time, go to the hall. The third time, walk in the hall. Each time, walk farther. That will keep your lungs from getting pneumonia, Mr. Washington.”

  The man nodded his head affirmatively. He took the incentive spirometer from the group and began inhaling.

  In the hallway, Dr. Wheeler pointed at Jackson. “Start him on clear liquids, Jackson. Put this clamp on the T-tube,” he said, handing a small metal clamp to the intern. Jackson wrote the instruction quickly on his clipboard. “Write to get him out of bed as well. Good.”

  The group moved down the hall to the next patient room. Rounds continued similarly, with visits to post-operative modified-radical mastectomies, colon surgeries, inguinal hernias, the ICU, and more spread throughout the morning. Dr. Wheeler and Thompson headed to the OR, the others striking out for morning general surgery clinic.

  They left Jackson to write progress notes on each of the 43 patients seen that morning. He had orders on his clipboard for the chart of each, and a list of scut work to complete. He would also report to the clinic after finishing his morning tasks.

  Scut work—the intern’s nightmare. Defined as monotonous, mundane, meaningless, or mindless, scut work in a hospital is nothing like that. The intern’s list catalogued many necessary jobs, from scheduling radiologic procedures, changing important dressings, to starting difficult IVs. In an academic setting, they could leave nothing on that list to unintended consequences. If left to chance, mistakes would often occur. “Assassins are everywhere” was the idiom, and Jackson left nothing to chance.

  One piece of scut that troubled the intern was changing the central line (CVP) of Mr. Mason, a Whipple procedure patient who was not doing well in the ICU. A Whipple procedure is a complex surgery that removes the cancerous portion of the pancreas. Nearly two weeks after surgery, Mr. Mason was still on a ventilator and was now draining bile through his incision.

  The patient’s CVP was at risk for infection, as it had been in the man’s neck the two weeks since surgery. He had a fever as well, and they discussed on morning rounds the possibility of contamination on the long, deeply placed neck IV. Jackson’s job was to place a long wire through the CVP, remove it, and slide a new IV in place.

  “Watch one, do one, teach one” was the guiding principle in the University Hospital surgical programs. As a fourth-year student in Boston, Jackson had watched the procedure. Now it was his turn to perform one.

  The CVP change went well. A chest x-ray showed the tip of the catheter correctly in the right atrium of the heart with no collapse of the lung. Jackson continued to the next piece of scut. It was to arrange a cholangiogram, an x-ray done through the T-Tube for the other gallbladder patient, Mrs. Feeler.

  “Hello, this is Dr. Cooper. I need to get a cholangiogram done this morning,” he said over the phone to radiology.

  “Who is this?” the lady on the other end asked with a hint of sarcasm in her voice.

  Jackson repeated his name. “I am a new intern on Surgery One. Can I talk to a radiologist?”

  “Well honey, I can help you.”

  “I need a cholangiogram on a Mrs. Feeler. She is one-week status-post cholecystectomy and is still draining through her T-tube.”

  “Well, y’all will have to talk to Dr. Kennedy about that, honey!” Without a goodbye, she put him on hold.

  “Kennedy here.”

  “Yeah, this is Jackson Cooper—you know, from Surgery One. Ah . . . I’ve got a patient after a chole who needs a T-tube cholangiogram.”

  “Send me a rec and we’ll get to it when we can, Jack.” Click—the line went dead.

  Jackson walked to the nurse’s station shaking, his head about the use of his least-favorite nickname, Jack. He filled out an x-ray requisition and placed it in the tube system to radiology.

  Afternoon rounds went as with the morning, except Jackson had to present each of the forty-three patients. They left ten history and physicals and an enlarging list of scut to him.

  At 11 p.m., his beeper went off. Returning the call, it surprised him to hear from Patrice Summers, the woman he’d met that morning. “Jackson,” she said. “This is Patrice. Can I check out to you?” Jackson was on call tonight, covering his general surgery service and cross-covering for the ear nose and throat (ENT) service. Patrice was evidently the ENT intern, and she wanted to check out her patients for the night to him. It surprised him, for it was her night off call and she was leaving the hospital so late. Soon he would learn, your night off was really not a night off.

  Her list went on and on, as the ENT service shared W3B and was quite busy. They discussed carotids, radical necks, rhinoplasties, and other surgical patients, including the deceased Mr. Simpson, one by one.

  As she finished describing her last patient, Jackson asked her if they could share a smoke sometime. “Oh, I don’t smoke,” the young doctor said with humor in her voice.

  “What’s with the smokes this morning?”

  “Oh, I just carry them, you know—for support. But I don’t smoke anymore. You should quit too, Jackson!”

  CHAPTER THREE

  His beeper went off during the dressing change. Glancing at the device on his hip, Jackson recognized the number of the surgeon’s lounge. The page occurred right in the middle of his work; that call would have to wait.

  Freddy Mason was a heavyset man of fifty-eight years who was status-post a Whipple procedure for pancreatic cancer in the head of the pancreas. Now two weeks post-op, he still needed ventilator support. In addition, the wound had dehisced—popped open—and begun draining green bile. Because of that, they charged Jackson with changing the wound dressings twice a day in the nurses’ stead.