Cutting For Stone Part 9

Ghosh took the proffered hand and while supporting it he felt for the radial artery. The pulse was bounding at one hundred and twelve per minute. Ghosh's equivalent of perfect pitch was to be able to tell the heart rate without a watch.

"When did this start?" he heard himself say, taking in the swollen abdomen that was so incongruent on this lean, muscled man. "Begin at the beginning ..."

"Yesterday morning. I was trying to ... move my bowels." The patient looked embarra.s.sed. "And suddenly I had pain here." He pointed to his lower abdomen.

"While you were still sitting on the toilet?"

"Squatting, yes. Within seconds I could feel swelling ... and tightening. It came on like a bolt of lightning."

The a.s.sonance caught Ghosh's ear. In his mind's eye he could see Sir Zachary Cope's little book, The Diagnosis of the Acute Abdomen in Rhyme. He'd found that treasure on the dusty shelf of a secondhand bookstore in Madras. The book was a revelation. Who knew that a medical text could be full of cartoon ill.u.s.trations, be so playful, and yet provide serious instruction? Cope's lines regarding sudden blockage of the normal pa.s.sage through the intestine came to him: ... rapid onset of distention

Will certainly attract your keen attention.

He asked the next question, even though he knew the answer. There were times like this when the diagnosis was written on the patient's forehead. Or else they gave it away in their first sentence. Or it was announced by an odor before one even saw the patient.

"Yesterday morning," Mebratu replied. "Just before the pain began. Since then no stool, no gas, no nothing."

Sometimes a bowel-coil gets out of place

By twisting round upon a narrow base ...

"And how many enemas did you try?"

Mebratu let out a short sharp laugh. "You knew, huh? Two. But they did nothing."

He wasn't just constipated but obstipated-not even gas could pa.s.s. The bowel was completely obstructed.

Outside the cubicle the men seemed to be arguing.

Mebratu's tongue was dry, brown, and furred. He was dehydrated, but not anemic. Ghosh exposed the grotesquely distended abdomen. The belly didn't push out when Mebratu took a breath. In fact it moved hardly at all. This is my work, Ghosh thought to himself as he pulled out his stethoscope. This is my grave-digging equivalent. Day in and day out. Bellies, chests, flesh.

In place of the normal gurgling bowel sounds, what he heard with his stethoscope was a cascade of high-pitched notes, like water dripping onto a zinc plate. In the background he heard the steady drum of the heartbeat. Astonishing how well fluid-filled loops of bowel transmitted heart sounds. It was an observation he'd never seen in a textbook.

"You have a volvulus," Ghosh said, pulling his stethoscope off his ears. His voice came from a distance, and it didn't sound like it belonged to him. "A loop of the large bowel, the colon, twists on itself like this-" He used the tubing of his stethoscope to demonstrate first the formation of a loop, then the twist forming at the base. "It's common here. Ethiopians have long and mobile colons. That and something about the diet predisposes to volvulus, we think."

Mebratu tried to reconcile his symptoms with Ghosh's explanation. His mouth turned up; he was laughing.

"You knew what I had as soon as I told you, right, Doctor? Before you did all these ... other things."

"I suppose I did."

"So ... will this twist untwist by itself?"

"No. It has to be untwisted. Surgically."

"It's common, you say. My countrymen who get this ... what happens to them?"

At that moment, Ghosh connected the face with a scene he wished he could forget.

"Without surgery? They die. You see, the blood supply at the base of the loop of bowel is also twisted off. It's doubly dangerous. There's no blood going in or out. The bowel will turn gangrenous."

"Look, Doctor. This is a terrible time for this to happen."

"Yes, it is a terrible time," Ghosh burst out, startling Mebratu. "Why here, if I may ask? Why Missing? Why not the military hospital?"

"What else have you understood about me?"

"I know you're an officer."

"Those clowns," he said, nodding his chin in the direction of his friends outside. "We don't do a good job of dressing as civilians," Mebratu said, wryly. "If their shoes aren't spit polished they feel naked."

"It's more than that, actually. Years ago, shortly after I arrived here, I saw you conduct an execution. I'll never forget that."

"Eight years and two months ago. July the fifth. I remember it, too. You were there?"

"Not intentionally." A simple drive into the city had turned into something else when a large crowd on the road had forced him and Hema into being spectators.

"Please understand, it was the most painful order I ever carried out," Mebratu said. "Those were my friends."

"I sensed that," Ghosh said, recalling the strange dignity of both the executioner and the condemned.

Another wave of pain traveled over Mebratu's face and they both waited till it pa.s.sed. "This is a different kind of pain," he said, trying to smile.

"You should know," Ghosh said, "that earlier today the palace called. They asked Matron to inform them if a military person came here for treatment."

"What?" Mebratu swore and tried to sit up, but the movement made him yell in pain. His companions rushed in. "Did Matron tell the palace?" he managed to ask.

"No. Matron told me she wouldn't turn you away knowing that you had nowhere else to go."

The patient relaxed now. His friends had a quick discussion, and then they remained in the room.

"Thank you. Thank Matron for me. I am Colonel Mebratu, of the Imperial Bodyguard. You see we had plans, a few of us, to meet on this date in Addis. I came from Gondar. When I got here I found the meeting had to be called off. We feared we were ... compromised. But I didn't get the message till I was already here. Before I left Gondar, yesterday, my pain began. I saw a physician there. Like you, he must have known what I had, but he told me nothing. He told me to come back and see him in the morning and that he wanted to check me again. He must have told the palace, or else why would they call the hospitals in Addis? Hanging will also be my fate if I am discovered in Addis. You must treat me. I can't be seen at the military hospital today."

"There is another problem," Ghosh said. "Our surgeon has ... he has left."

"We heard about your ... loss. I am sorry. If Dr. Stone can't do it, then you have to."

"But I can't-"

"Doctor, I have no other options. If you don't do it, I die."

One of the men stepped forward. With his light beard, he looked more like an academic than a military man. "What if your life depended on it? Could you do it?"

Colonel Mebratu put his hand on Ghosh's sleeve. "Forgive my brother," he said, then smiled at Ghosh as if to say, You see what I have to do to keep peace? Out loud he said: "If something should happen, you can say in good faith that you knew nothing about me, Dr. Ghosh. It's true. All you know about me are all the things you guessed."

GHOSH DIALED Hema's quarters. It occurred to him that Colonel Mebratu and his men must have been plotting some kind of a coup. What else could the secret meeting in Addis have been about? Ghosh was faced with a conundrum: How did one treat a soldier, an executioner, who now was engaged in treason against the Emperor? But of course, as a physician, his obligation was to the patient. He felt no dislike for the Colonel, though he could do without the brother. It was difficult to dislike a man who bravely suffered physical pain and managed to retain his manners.

Over the hum of the receiver, Ghosh could hear the blood rushing into his ear with every heartbeat.

Hema's brusque "h.e.l.lo" told him she was scowling. "It's me," he said. "Do you know who I have here tonight?" He told her the story. She interrupted before he could finish: "Why are you telling me this?"

"Hema, did you hear what I just said? We have to operate. It's our duty."

She wasn't impressed.

He added, "They're desperate. They have nowhere else to go. They have guns."

"If they are so desperate, they can open the belly themselves. I am an obstetrician-gynecologist. Tell them I just had twins and I'm in no condition to operate."

"Hema!" He was so mad that words would not come out. At least in the business of patient care, she was supposed to be on his side.

"Are you minimizing what I have on my hands?" she said. "What I've gone through just yesterday? You weren't there, Ghosh. So now these children's every breath is my responsibility."

"Hema, I'm not saying ..."

"You operate, man. You've a.s.sisted him with volvulus, haven't you? I've never operated on volvulus." By "him" she meant Stone.

The silence was punctuated only by the sound of her breathing. Does she not care if I get shot? Why take this att.i.tude with me? As if I'm the enemy. As if I caused the disaster she walked into when she returned. Did I invite the Colonel here?

"What if I have to resect and anastomose large bowel, Hema? Or do a colostomy? ..."

"I'm postpartum. Indisposed. Out of station. Not here today!"

"Hema, we have an obligation, to the patient ... the Hippocratic oath-"

She laughed, a bitter, cutting sound. "The Hippocratic oath is if you are sitting in London and drinking tea. No such oaths here in the jungle. I know my obligations. The patient is lucky to have you, that's all I can say. It's better than nothing." She hung up.

GHOSH WAS an internal medicine specialist through and through. Heart failure, pneumonia, bizarre neurological illness, strange fevers, rashes, unexplained symptoms-those were his metier. He could diagnose common surgical conditions, but he wasn't trained to fix them in the operating theater.

In Missing's better days, whenever Ghosh popped his head into the theater, Stone would have him scrub and a.s.sist. It allowed Sister Mary Joseph Praise to relax, and for Ghosh, being the first a.s.sistant to Stone was a fun change from his routine. Ghosh's presence transformed the cathedral hush of Theater 3 to a carnival racket, and somehow Stone didn't seem to mind. Ghosh asked questions left and right, cajoling Stone into talking, instructing, even reminiscing. At night, Ghosh sometimes a.s.sisted Hema when she did an emergency C-section. Rarely, Hema sent for him when she performed an extensive resection for an ovarian or uterine cancer.

But now he found himself alone, standing in Stone's place, on the patient's right, scalpel in hand. It was a spot he hadn't occupied for many years. The last time he stood on the right was during his internship when, as a reward for good service, they let him operate on a hydrocele while the staff surgeon stood across and took him through each step.

On his instruction the circulating nurse pa.s.sed a rectal tube into the a.n.u.s, guiding it up as high as it would go.

"We better start," he said to the probationer who was scrubbed, gowned, and gloved on the other side of the table, ready to a.s.sist him. Her faint pockmarks were hidden by cap and gown. Even though her lids were puffy, she had beautiful eyes. "We can't finish if we don't start so we better start if we're to finish, yes?"

A very large incision should be made

-of small ones in such cases be afraid-

The coil brought out, untwisted by a turn

-a clockwise turn as you will quite soon learn-

And then a rectal tube is upward pa.s.sed-

Thereon there issues forth a gaseous blast ...

With the colon swollen to Hindenburg proportions it would be all too easy to nick the bowel and spill feces into the abdominal cavity. He made a midline incision, then deepened it carefully, like a sapper defusing a bomb. Just when panic was setting in because he felt he was going nowhere, the glistening surface of the peritoneum-that delicate membrane that lined the abdominal cavity-came into view. When he opened the peritoneum, straw-colored fluid came out. Inserting his finger into the hole and using it as a backstop, he cut the peritoneum along the length of the incision.

At once, the colon bullied its way out like a zeppelin escaping its hangar. He covered the sides of the wound with wet packs, inserted a large Balfour retractor to hold the edges open, and delivered the twisted loop completely out of the wound onto the packs. It was as wide across as the inner tube of a car tire, boggy, dark, and tense with fluid, quite unlike the flaccid pink coils of the rest of the bowel. He could see the spot where the twist had occurred, deep in the belly. Gently manipulating the two limbs of the loop, he untwisted, clockwise, just as Cope said. He heard a gurgle and at once the blue color began to wash out of the ballooned segment. It pinked up at the edges.

He felt through the bowel wall for the rectal tube that Nurse Asqual had inserted. He fed it up like a curtain rod in a loop. When the tube reached the distended bowel, they were rewarded with a loud sigh and the rattle of fluid and gas. .h.i.tting the bucket below. "And down the coil contracts and you will see, the parts arranged more as they ought to be," Ghosh said, and the probationer, who had no idea what he was talking about, said, "Yes, Dr. Ghosh."

Ghosh flexed his gloved fingers. They looked competent and powerful-a surgeon's hands. You can't feel this way, he thought, unless you have the ultimate responsibility.

AFTER HE CLOSED, as he was stripping off his gloves, he saw Hema's face in the gla.s.s of the swinging doors. It disappeared. He charged after her. She ran, but he soon caught up with her in the walkway. She stood panting against the pillar. "So?" she said when she could speak. "It went well?"