Scythe Upon the Grasses by Dr. Mina N. Le

Scythe Upon the Grasses

Some must employ the scythe Upon the grasses, That the walks be smooth For the feet of the angel. ~Philip Larkin

That January, I was an intern on General Surgery, working 100-hour workweeks. Every fifth night, I took overnight call, covering more than five dozen hospitalized patients, including complicated Cardiothoracic and Transplant patients, in addition to handling direct admissions. There would be life-and-death crises. When I was on call, I wouldn’t get a lick of sleep all night. Dr. Bellaire was the bright light of that month for me. He was bookish and intellectually inclined like me; we could talk to each other. This mattered for a lot when I felt like an outsider, not only as a woman in surgical training, but also as a Southerner relocated to Minnesota just six months before. When we would rhapsodize about Plato and Shakespeare over our hernia repairs and appendectomies, I’d regret that he had to be twice my age and my attending. I would thrill when he put his gloved hand on mine to guide my instrument, or when we made eye contact over our masks; his eyes behind his glasses had a soulfulness to them. During one hernia case he asked me, as we dissected the abdominal wall, “What three arteries do you expect to find at about this level?” Although it was possible that his question was directed at our medical student, I was eager to impress him, so I spoke up quickly: “The superficial external pudendal, the superficial circumflex iliac, and the superficial epigastric.” He replied, “Wow! I’m impressed! I’ve never heard an intern reel off the right answer like that.” I’m generally suspicious of compliments, but this one was even more suspect: how could that be true? Didn’t categorical interns actually study this stuff? Then he cast a shadow on the whole thing by saying, “Did someone tip you off that I always ask that question?” I was taken aback, deflated. Absolutely no one had tipped me off. Credit was due to my own insight into what to read the night before, not to someone helping me cheat, and I was irked that I had no way to prove it.

One Wednesday evening late in the month, Dr. Bellaire came into the physician workroom as I was signing out to the intern on call. There were going to be two organ procurements that night: would I be available to help? I was no longer on his service by then, so this would be purely voluntary. The pain of it was that I’d been hours away from only my third day off in nearly four long weeks. Transplant also wasn’t important for me to learn, given that I wasn’t planning to become a general surgeon. Tactfully hesitating, I asked, “Will I be useful?” I knew he was already going to have a fellow, someone five years senior to me, as his first assistant. “You will be,” he said, and that was enough for me to take it. The plan, he said, was as follows: a taxi would pick us up outside our emergency room at 10 PM and take us to the first hospital, where a team from the Mayo Clinic would be harvesting the liver. We’d take the

kidneys and pancreas. From there we’d be driven to the second hospital, where the heart had been promised to a team at Michigan, and all the solid organs of the abdomen would go to us. It wouldn’t be our job to put the harvested organs into new patients; that would be a daytime task for other teams. We would only be performing the surgery to get the organs out of people who were newly brain-dead. “Go home and take a nap first,” he said, from the doorway of the workroom. I went home and tried, but it was too early to fall asleep. I couldn’t manage it.

I arrived in the emergency-room parking lot at 9:55 PM, the first team member to get there. It was bitterly cold, even for Minnesota in January. The Transplant fellow joined me in the backseat of the cab, Dr. Bellaire sat down in front, and we were off. We were driven to a private hospital not affiliated with our university training program, where we had to stop at the information desk and ask for directions to the operating room, then head to the locker rooms to change. Even though the hospital was new to me, every operating room is still similar and still feels like home: it was past ten o’clock at night, but the lights were bright and the nurses cheerful, garbed in uniform blue. I asked, “This is OR 7, right?” One of the circulating nurses replied, “Oh yes. This is the only OR going right now. And it’s the only one that looks like that,” gesturing to the patient on the table. She was referring to the fact that in most operations, you cut as small an opening in the skin as you need to get the job done. In contrast, this patient’s chest and abdomen were wide open to the air, lungs on display, intestines spilling out. A team of three surgeons from the Mayo Clinic, which is an hour and a half away, were hard at work on extracting the liver. We had to watch them at first, since there wasn’t space for all of us to operate on the body at once. The patient was a 65-year-old man who had bled into his brain. Since his organs were so old, they wouldn’t be useful for transplantation into other people, and I learned that we were actually harvesting them for research in the lab. Once the Mayo people had made off with their liver, the three of us stepped up to the operating table, where Dr. Bellaire guided the fellow, David, through the procedure. My assignment was to sew up the partly emptied body at the end. “Just do a makeshift job,” Dr. Bellaire told me. “They’re going to open him up again for embalming.” He showed me what technique to use: a crude “whip stitch,” leaving a stripe of conspicuous diagonal blue lines on the man’s pale skin, from his breastbone to his pubis.

It was almost two o’clock in the morning when we were done, but we learned that the second procurement wouldn’t be going until 4 AM, so we had two hours to kill. “Why don’t we go and knock back a few beers?” David said to Dr. Bellaire, at the door to the men’s locker room. “Why don’t we go to Sex World?” “Ooh, don’t leave me out of that,” I said, and they laughed. We ended up grabbing some chicken Kiev in the hospital cafeteria and then taking the taxi back to the U for a nap in the resident lounge. The only problem: there were only two couches in the lounge, and two shortbacked recliners. I put the two recliners together foot-to-foot and leaned them each back, creating a sleeping surface with several up-and-down angles. “I’ll take that one,” said Dr. Bellaire. “No, I’ll take it,” I said.

“No no, you two take the couches.” “I’m sleeping here,” I insisted, getting onto the recliners. He looked at me, and I held his gaze, feeling uncomfortably disrespectful as an intern arguing with an attending, but also refusing to let him have less than “the best seat in the house.” Finally he relented and went to gather pillows and blankets, and he and David lay down on the couches. At this time two young people not wearing scrubs, perhaps Internal Medicine residents, came into the lounge. It was a guy and a girl, and they were surprised by our presence. I heard them say something about obtundation, and Dr. Bellaire asked them about their obtunded patient. The guy was disproportionately animated in discussing it, and then the two of them abruptly left the room. “Did you notice,” observed Dr. Bellaire, “that they weren’t really talking about obtundation when they first came in?” “Ohhh!” I said, putting it together. “They didn’t think we’d be here,” he said. We turned the lights off, and set our alarms for an hour. Again I couldn’t sleep. An hour later, I was the one exhorting the other two to rise. After Dr. Bellaire sat up, I sat down on his couch, a decorous distance away from him. The couch was all warm from his having slept on it, and I could feel the warmth through my back, shoulder, and arm, exciting me. “Did you get any sleep?” he asked me. “No,” I said honestly. “Aw,” he said softly, giving me a tender look. “I thought you did. You looked so peaceful.” It gave me a rush to realize he’d been watching me while he thought I’d been asleep, and while I thought he’d been asleep.

Armed with three cans of caffeinated soda from the vending machine, we set off at four in the morning. The ride to the second hospital took us through the most dangerous part of town, North Minneapolis, which David explained was known as “Murderapolis” when he was growing up. The female taxi driver remarked that she would normally take the freeway shortcut, and not tackle these city streets. “But tonight it’s so cold that no one’s going to be out trying anything.” This patient was a 39-year-old woman who had been in a car accident. She had flown out of an SUV and hit her head. Because she was young and healthy, her organs were being harvested for transplantation into other people. Her husband had signed the consent papers. It turned out that Michigan had turned down the heart, for some reason. A surgical team from Loyola University in Chicago had flown up to take it for themselves. One of the kidneys was destined for North Dakota, while the other kidney had been claimed by a local hospital. I noticed that her pancreas was beautiful, not like the old man’s fatty, misshapen one. She lay opened on the operating table, small-breasted, her nipples erect. At the beginning of the case she was technically alive, and the dissections had to proceed carefully with the cautery, because she bled like any living patient. Then at one point the anesthetist stood up, said, “You don’t need me anymore,” and left the room. The woman had transformed from patient to cadaver. Henceforth the organ dissection went quicker because it could be done with scissors, as she no longer bled where she was cut.

We gathered the organs we wanted, and the body was transferred to a gurney bearing a body bag.

Early that morning, our work was done and we were sitting in the emergency room lobby waiting for our next taxi. I was carrying the box that contained the pancreas, while David was carrying the box that contained the liver. “You know,” I said to Dr. Bellaire, “I keep meaning to ask you if you knew my aunt. She was a resident at Mass General during the same years that you were.” I said her name and he said, “That sounds familiar. I definitely knew her. Hell, maybe I even dated her!” “Jesus Christ!” I said in disgust, even though I knew he just was kidding and trying to get a rise out of me. Back at the U, David and I branched off and went to the operating room, where he had me stand guard over the liver and pancreas while he went off to find the person to pass them off to. I looked at the day’s OR schedule and saw a new case listed, newly added since the day before:

Cadaveric Liver Transplant

We had just made that operation possible. Someone with end-stage liver failure was about to get a new lease on life. They would have just received the telephone call the previous evening. Looking up at that screen, reflecting on the way we’d stayed up all night to get someone that liver, I blazed with pride for my chosen profession. Dr. Bellaire returned and held out his fist palm-down. I thought he wanted to fist-bump. It took a moment before he could explain what he wanted me to do. Finally I put up my open hand under his fist, and he uncurled his fingers and pressed two pieces of chocolate into my palm. “They’re not Hershey’s,” he said as he walked away. He knew I hated Hershey’s. When I went home I was too sleepy to be productive, so I stayed up idly until mid-afternoon and then slept until it was time to go back to work on Friday morning.

Mina N. Le, MD Assistant Professor, Department of Otolaryngology-Head and Neck Surgery Rutgers New Jersey Medical School