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Sidney Schwab

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Member Since: May, 2006

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Thought Process
By Sidney Schwab
Tuesday, November 27, 2007

Rated "R" by the Author.

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A story of a surgeon on the other end of a knife -- an attacker's knife.

THOUGHT PROCESS

Because he was a surgeon, he knew exactly what was happening. As he threw his shoulders forward, bent his knees, flung himself backward like a squid, trying to avoid the thrust, he knew. And he felt it playing in his brain, digitally, frame by frame, cell by cell, in the endings of his nerves, in advance, even before his shirt was rent. Surprised, he found he had more than enough time to consider and to abort his reflexive notion to grasp the blade as it entered. To visualize popping tendons, flailing fingers; to see his career end only eight years after it began; reflect on the sleepless decade he’d spent getting here, gratification deferred. So he didn’t, and except for the pinkie, his fingers avoided what his belly did not. In retrospect, handing over the wallet sooner would have been a better choice. If it were a choice.

Later, he couldn’t say if he’d really felt everything or if it was just a replay mix of the thousands of operations in which he’d been on the other end. At the time, though, every particle was clear, sensed in perfect detail. The skin, indenting, little hairs bending toward the knife. Releasing outward as the dermis breaks and snaps forward, micro droplets of blood flung up and away. Fat cells spilling saffron-yellow oil, lubricating the steel and wiped away before its beauty – its vegetable pretensions – could be fully apprehended. Leathery fascia over his abdominal muscles providing a noticeable but brief resistance, futile protection of the red meat below. He could feel the muscle fibers split along their length, parting gracefully, like the sweeping hand of a palace guard, as the knife made its way deeper. He felt the second layer of fascia yield and he could see the stretch of the peritoneum, plastic wrap, hear the crack of it as it gave way. Then the track became more of an inference: stomach most likely. Colon? Not the cava. Please, not the cava. But it was the splenic vein about which he had no idea, couldn’t feel at all, didn’t even guess, which nearly killed him then, and there. And the pancreas, which ultimately made it more than just a pain in the ass.

Hang on, you’re gonna be fine, someone says. Five minutes away. Did you see the guy?

There was little residual memory of the emergency room, especially the first of it. As vessels refilled finally with fluids, two IVs running, the blood pressure came back some, and with it enough brain function to embe d recollection. His belly was hurting, there was pain in his shoulders: something must be leaking in there. Questions coming from both sides, numbers, names, people poking him, reaching around his back. Someone calling for O-negative blood. Huh. Gimme anything you got. Girl grabbing me, probably shriveled like a raisin, shoving in a catheter. The clean underwear thing, but I always worried they’d laugh at my dick. A stomach tube went in, too, through his nose, and for the first time ever, he didn’t gag. In med school he’d ruined some experiment or other, a lab, when he yanked his after half an hour. Half the class couldn’t even get them down. Maybe when it’s necessary, the brain lifts restrictions. Through muffled layers came the realization he might die.

The OR was like a bucket, dull and clanging. People counting instruments somewhere far away, talking into the wind: eight kelleys, four scissors... Lap pads. Seven eight nine… Ringing sounds, tape tearing. Something fell on the floor. I’ll need another Metz, said a voice with no head. It hurt again when they rolled him onto his side and slid a roller under, dragged him off the gurney and onto the table. He reached out to catch up with his body, trailing after it like a slow shadow. Someone forgot the urine bag, pulled on the catheter, stretching it hard. Oops, she said. Hope he’s got a good prostate. In training, you said oops, you got tossed out for the day. He knew he was naked, cool, too cold. Arms on rests, crucifixed, feet crossed, knowing better: nurses separate them, people put them back, over and over, until they’re asleep. A clip on his finger, stickies on his chest, then the beeps of the monitors. Counting the rate: he couldn’t help it, and they ran too fast. Am I still in shock? A hand on his upper arm, near the armpit, like his wife. He tried to flex his biceps, as he did when it was her hand. Jesus, who am I? Stinging in his forearm, another headless voice saying, we’ll take good care of you. I thought I was the only one who said that. We’re all bullshitters. Sounds of the suction being connected, swoosh, loud, the kind that, when finally turned off again, at the end of it all, feels good, the surprise of silence. Fluffing of the drapes, clicking in place of the light handles. And that was pretty much it.



In the recovery room, he lifted his head, propped one elbow and looked around as he tried to figure out where he was and remember why. A nurse looked back from far away. Are you hurting, she asked. No. Yes. I don’t know. Dumbly, he reached for the cannula blowing oxygen under his nose, hand flapping too far to one side, then the other, head bobbing as if in a tub of water. For no reason that he knew, he pawed, paretic, at the hose, managed to get one vent outside of one nostril, blowing into his eye. I’m a damn cliché, he realized, and grundled back onto the gurney. Later, as the night came to light in his brain, he began to take measure, palpating, fingering little data points into sensibility. He felt a suction bulb attached to a drain tube. Not good. The bandage stretched from manubrium to pubis. Also not good. And then. Oh shit. A goddamn fucking bag. Empty, for now. Son of a bitch. Gimme some of that morphine, baby, and make it go away. She did, and it did.

Pain is okay. Takes your mind off everything else, and it’s better than nausea. He had a push-button to give himself a slug when he wanted, but he didn’t use it much. Focusing on the throb in the center of his belly, he let it get bigger and bigger until it was warmth, washing over him. The opposite of overcoming it, he made it so big it became something else, the sky, the world, and he was small within it. I can take it, he thought. I want it. Probably deserve it. He thought of some of his patients, the ones that always wanted more, who looked wounded and suffered and wouldn’t get up, and he felt superior. Doctors make lousy patients, he thought, but not me. He rolled onto his side and bent his knees; it felt familiar and for a moment he was back in the night. He pushed himself up, and sat dangling, grunting. This is me at my best. I do misery like I’m wearing it. Then, out loud, he said fuck me.

When his son came for the first time, fear was smeared on his face like blood. No one should feel that way about me, especially my kid, he thought, and it brought tears. It’s okay kiddo, he said, I’m fine, it looks a lot worse than it is. Can you come over here? He didn’t. After the child left, he removed his own catheter and pulled out his stomach tube. Fuck me, he said again. Fuck the sonofabitch that did this.

His surgeon had been apologetic. I hated to do the colostomy, he’d said, but it got your pancreas, too. You were in shock, we took your spleen, I thought if I sewed up the colon it’d fall apart. Would you have? I don’t know, he’d answered. I guess not. Maybe if I was operating on myself. Three months minimum, the surgeon said, before we go back in. And he saw the wound hardening, thickening up, the capillaries multiplying, turning the tissues into bloody sponge, then stone. Before it began, he sensed the fibroblasts pouring proteins into the spaces between his bowel and abdominal wall, the layers swelling beyond their natural boundaries, obliterating the planes for proper dissection, cementing together bowel (small to large, loop to loop), abdominal wall, the fatty apron of omentum. He knew, because he’d been there, that the window closes within a few days and, as if painted shut, is nearly impossible to open until those processes reverse over several months, softening, shrinking, disengorging. Let’s get back in there now, he thought, tomorrow, before it’s too late. I’ll take the chance. But he said nothing.

She’d been there in the recovery room, holding his hand and twirling the hair behind his ear, but his first recollection of seeing his wife was the next morning. With her blue bag full of magazines and books, she’d been sitting beside him, one hand holding a book, the other resting on his knee, under the covers. Said hi when she saw he was awake. I’m sorry, he’d said. How are you, she’d asked. I’m sorry, he’d said again. For what? I don’t know, just the whole thing. That you have to go through this. Me, she’d said. Just the whole thing. I don’t want you to have to worry, to have to… worry… And then he’d drifted off. It went like that for the whole first day.

“Visitors must check at the desk,” the sign taped to his door. Friends, even doctors and nurses, not really welcome. Same with family, of which there were many. It wasn’t just the bag, or the smells, or his puniness. He hated the look on the faces, the worry, the we-love-you’s. It all made him feel bad, undeserving. It made him want to weep. They don’t know me, none of them do.

The surgeon wasn’t pleased about the de-tubing, but by then he’d already peed, and he wasn’t bloated. You asshole, the surgeon said. He smiled when he said it, but he walked out right after.

To the cops, he hadn’t much to say. It was a skinny white guy, probably an addict. Bad teeth, ratty hair, too dark to see color. Chin hairs, furry lip like a kid, but looked older. Thirties. No marks. The fucking drive-through cash machine was broken, so he’d parked and gone to the one in the wall. Guy was standing by the car when he came back, said something classic like your wallet or die, flashed a blade. He’d thought about it a little too long, uttered a stupidity, and that was it. Would you recognize him? Not sure. Maybe. Probably not. We’ll bring some pictures. Great. Talk about clichés. His house had been robbed once; nothing and no one ever turned up. Likewise, he figured, this time. And, it turned out, he was right.

The misery of recovery perked him up. Insisting on using the stairs, he rejected the idea of a bed in the living room, and he stayed in the guest room, alone. We’ll both sleep better, he said, and it was true . For the first couple of days he accepted soups in bed, but he got up and down on his own. The percocet stayed bottled. He bagged and unbagged by himself, did his wound, and, as he got to that point, made his own meals. Sandwiches. Having appropriated more than a few surgical scrubs over the years, he wore them, and washed them himself. Those are my juices, he said. It’s not your problem. Knowing this about him, his wife let it go; it’s what he needs. Grunting to himself, satisfied in his struggle, he kept the walkway swept, sat down and leaked when he was done. His son was solicitous, but quiet. Sometimes it seemed like he might cry when their looks engaged. Shattered illusions. It embarrassed him, and angered. He kept working on getting strong enough to work. It’s what the kid needs, and me, too.

In half the time the surgeon recommended, he was back. Starting with half days, he saw consults, carved out lumps and bumps, in the office. He was upfront about the attack and its consequences. The gurgles and burps of his belly. People were sorry. Yeah, well, sometimes life sucks. But I’m still a liberal. Y’know, feel your pain. Because he changed the sheets in the exam room as he’d always done, joked with his patients, ruffled kids’ hair, his nurse felt he’d be okay. She saw him sitting down once in a while, back straight, eyes closed. Gripping the armrests. And, like his wife, let it go.

When he returned to working in the operating room, he never asked and no one ever told him if there was a protocol for surgeons with colostomies. Before each case, he’d ask for a plastic drape, the kind with an adhesive strip along one edge, take it back to the locker room. In a stall, he’d lift his scrub shirt, hold it with his chin, staring down at his bag. Lay the strip across his ribs, hang the drape over his belly. After a couple of weeks, he started doing it at the scrub sink, in the open. Some people made a point of watching, some of not. Gowning up, getting a glove on over his stiff pinkie foretold the day, for a while. If it got stuck, and the nurse went to adjust the finger, he’d recoil. I’ll do it, he’d say, snapping the rubber like releasing a slingshot.

He started with hernias, a couple at a time. Gallbladders. Eventually he felt he had a full measure of stamina and let his office know to schedule all comers. The first colon resection was like a homecoming. Since watching his mentors and learning it himself, sewing bowel together was transcendent joy. Placing sutures below clamps on each end, turning the semicircular needles in a perfect arc, laying the ends out in parallel, six or eight, exactly spaced. Tying them in a blur of fingers, tension just enough. It took a sense of tissue turgor, of sealing without strangling, and he gauged it in a way that gave pleasure and which, he felt, couldn’t be taught. Just had to have it. The inner row, laid in after removing the clamps, run up to and around the corners, bringing the bowel ends together and inverting the edges to create a smooth surface. No staplers: classic technique, come down from the oldest of masters. Some people made it look lumpy and uneven. Not him, not ever. It was his gift to his patient, unseen, unknown, art at its most own-sakeful. I can always tell your work, scope-doctors would tell him. Pristine, like no one was ever there. When he got his own hooked together, he knew it wouldn’t look like that. And when he looked into others, he kept seeing himself.

They made their annual trip to Hawaii. He sat in the shade, reading, never removing his shirt. In past years, he’d spent hours in the pool with his son. Crouching underwater, holding his breath as his son scrabbled up his back and onto his shoulders. Grabbing the boy’s ankles, waiting until he stood erect, then standing himself, making a two-man totem. When they both had their arms spread out, he’d say Barnum, and his son would answer Bailey. Sometimes he stayed under long enough for another kid to situate on his shoulders, and his son to get on the second’s, as he reached above and held his son’s hands. Then he stood, exhaling persuasively, a stack of three, when it worked, when they didn’t collapse. What his son liked most, and what he repeated past exhaustion was to uncoil fast and hard, when the boy was standing, firing him high, arcing into the deepest end, screaming. Kids lined up for that one, and he accommodated them all. Not a surgeon, just a dad. This year, nobody. Robbed again, wounded once more, he stared into his book, and his son looked away.


* * * * *

He’d stopped checking with the police, and they with him. He was back to situational tiredness, the surgical kind having healed away. Taking emergency call every third night, hauling himself out of bed when he couldn’t convince the ER doc it could wait. Driving in, the tightness in his gut was back to the old kind, coming from worry about what he’d find, could it be something he couldn’t fix, colliding cars, a smashed liver, a torn aorta. This night it might be simple. A gut-shot, cop versus bad guy. Jesus, he said, walking into the trauma room, inhaling the scene, reading monitors from across the room, seeing if the guy was awake, tipped into shock position or not. Why can’t you shoot people in the daytime? Nice to see you, doc, the cop said.

Too improbable ever to have thought about it, the idea sprung from nowhere. There were fewer teeth, no surprise, and he seemed too old. But the scraggled chin and the furred lip, the skinny hand, even in too much light, looked the same, seemed the same. And the clamminess he felt was real enough, entirely familiar. The cold in his armpits, the sudden stink. Were someone to look his way, she might wonder. You guys are doing good, he said, turning away. I’ll call the OR. You got people? I got a case. And after he told them what he needed, he sat and thought, pressing hands hard to temples, where arteries throbbed. He’d operated before on people a little too close, a partner, a brother-in-law. Nurses he knew well, and good friends. Always concentration trumped connection and the person became, simply, patient. But this. This was the opposite; and a gift, if he wanted to take it. Normally a frustration, an impediment to artful surgery, the crew he’d have tonight worked mainly with orthopedists. Having a scrub nurse who didn’t know his routines, who never had the right instrument ready, meant stops and starts, impeding the musical flow of an operation well done, by a seasoned team. An assistant who couldn’t anticipate was dead weight. As soaring as surgery could be when it all came together, joyful and symphonic, working with unfamiliars was nothing but a series of obstacles, and it happened all too often. Tonight, though, could make up for a thousand aggravations. If no one knew what he was doing, he could do what he wanted.

It would be easy. There were dozens of possibilities, and he could make something of any of them. From the entrance wound, a .38 police special, there was no doubt there’d be plenty of damage, holes in gut, probably a few. No one who’d be there with him would have a clue about what needed to be done, or how. Traveling through the backside of the abdominal cavity, the bullet might have gotten the kidney, or duodenum, colon, pancreas. As long as there wasn’t a growing blood collection, he could ignore it and no one would care. An artist in reverse, he imagined skillfully misplaced stitches; considered how depth and tightness and spacing and suture choice could be used to time the leaks. An undrained pancreatic or duodenal injury along with a leaking colon would be disastrous. That he could manage something was not in doubt.

Well-trained, and compulsive, he was a surgeon whose patients rarely had complications, and when they did his shame and sorrow were evident to everyone within the radius of his care. As long as such a patient remained in the hospital, he felt branded and exposed. As he sat, head still pressed between his hands as if to keep his thoughts from view, it was this that he contemplated: the blot on his reputation, a poor patient outcome. This, if he pulled it off, would be hard to take. With nothing like it on his record, though, it wouldn’t really have consequences. Yeah, and times were changed. Screw ‘em. He had a plan.

He wheeled the gurney himself to the elevator, looking down at the man, trying to match what he saw with his recollection. Alert and staring, the man had remained resolutely silent, giving nothing away. If there was recognition, it didn’t show. It’d have been helpful to hear his voice; still, he didn’t doubt this was the guy. In the elevator, he leaned down to whisper in his ear: I know who you are, motherfucker. But he didn’t. What he did say, later, as the man was going off to sleep: we’ll take good care of you. Gripping the man’s arm, hard, his own hand cold and wet and trembling.













 

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Reviewed by Kevin Connolly 11/29/2007
Interesting take on a story that has been done before. No complaints except for something that reminds me of Bye Bye Birdy. The male lead, an author of musical comedies who is leaving Broadway to attend dental school (hey, I thought only med school washouts went to dental school!) has to write a new song for Conrad to sing to the female supporting actress before he ships out to Fort Dix for basic.

"One last kiss,
One last kiss,"

And then he blocks before coming up with a rhyme:

"I love your dentifrice"

At which the female lead opines "Too clinical."

I don't have a problem with the graphic description of penetrating abdominal trauma (though I suspect some readers stopped at that point) and it's not really a problem, but sometimes the lingo sends me to google (even though I was offered entry to Downstate as a second year subject only to completion of A&P) and the jargon is sometimes a bit much. And I don't get "jellyfish in systole" (well, I do get it, it's just that I never thought of a jellyfish as having systole or anything else referring to a heartbeat).

One final thought: after setting up the colostomy angle and how very angry/depressed the narrator is about that aspect of the injury, you did not say anything about the perp going home in a bag of his own.

As always, your writing is lucid, expressive, and illuminating. I just do not think you have dumbed it down enough to have mass market appeal, for which you have my applause.
Reviewed by Nickie Coby 11/28/2007
What a great story! This would get a 5/5 in my book, the imagery is wonderful.
Reviewed by Justine Hemmestad 11/28/2007
Dr. Schwab,
I think you're a wonderful writer!
Sincerely, Justine Hemmestad

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