Chapter Twenty-Six

August

Sarah Berenson was the girl I swore I would never forget. She was young, she was beautiful, and she was going to die if we couldn’t help her.

I met Sarah during my second month on Bill Kramer’s service. Bill was the youngest of the three orthopedic oncologists at Mayo. I had been leery about working with him. I was nervous not only about being a senior resident, but also about working in oncology. Oncology was the antithesis of orthopedics. In ortho, we generally dealt with healthy people and solvable problems. People came to us with torn cartilages—we removed them and they were better. People came to us with broken legs—we set them and they were better. People came to us with arthritic hips—we replaced them and they were better. I loved orthopedics. I loved going to work each day and fixing things. I loved the incredible feeling of accomplishment in what we did.

But oncology is a different story. Oncology means cancer, and cancer usually wins. Pity the poor oncologist, I thought, losing many more battles than she wins; no grateful patients thanking her every day, no tangible results affirming her competence, no happy endings. A lifetime spent signing death certificates, not op reports. Oncologists, I concluded, were better people, stronger people, than I. They did their job, they treated their patients, but they reaped none of the adulation we orthopods took for granted.

 

Sarah was an eighteen-year-old girl with osteogenic sarcoma of the left ilium. She had been referred to Mayo by her family doctor in Los Angeles. He told Sarah she had “a growth,” it might be bad, and she needed to go to the Mayo Clinic “right away.” We were left to tell her it was indeed bad, and that her only hope was a radical operation called a hemipelvectomy, in which we would remove not only the entire leg, but half the pelvis as well. Even with this mutilating surgery, Sarah’s chances of survival were not good.

Sarah was a vibrant, beautiful, young woman with a perfectly proportioned body, and eyes that radiated innocence and trust. This is the Mayo Clinic, her eyes said. You will cure me. Before we had done a thing her eyes were thanking us.

Part of me liked being thanked by this beautiful young woman. It was an acknowledgment of our power, our skill. But I was uncomfortable, too. Her thanks, her trust, placed upon us a burden I wasn’t sure we could shoulder. This was my first rotation as a senior resident and I was still naive enough to want to fight every bad guy, and to win every fight—but I knew the statistics, too. Sarah had osteogenic sarcoma of the ilium. The five-year survival rate was less than five percent.

But I wouldn’t listen to the voice that tried to reason with me. I preferred to listen to Sarah’s voice telling me how wonderful I was. I envisioned her arms around me, her wet tears on my neck as she thanked me for saving her life.

I was attracted to Sarah—but in a way I found hard to define. I wanted to be everything to her. I wanted to be her brother, her doctor, her lover—but mostly I wanted to cure her. I wanted to say, “We’re going to beat this thing, Sarah, you and me.” (Well, mostly me. I was going to beat it for her. It was to be my gift to her.) Cancer was the big bully forcing itself on this beautiful, virginal creature, and I was the guy who was going to stop it. We were going to drop the gloves and go at it. “Let’s go, shit head. Right now. You want Sarah? Well, you’ll have to come through me first.”

Yeah, right. After cancer had beaten me to a pulp a dozen times in a row I would learn to keep my emotional mouth shut.

I went to Sarah’s room the night before surgery. I didn’t usually do that, and I didn’t attempt to explain to myself why I did it that night. Five percent five-year survival, I was telling myself. That’s five percent, not zero percent. That means some people make it. Sarah has to be one of those people.

It was after ten by the time I got to her room. Her parents had already left. Sarah was lying in bed, her blond hair splayed across the pillow. Her eyes lit up as I entered the room.

I started to smile, then looked away. I flipped through her chart for several seconds, then closed it. I looked at Sarah, then opened the chart once again and pretended to read something. Finally I laid the chart down and asked Sarah how she was feeling.

“Okay,” she replied.

I went through the usual pre-op instructions. I told Sarah she should not eat or drink anything after midnight. I reminded her that the orderly would come for her at six o’clock the next morning. Then I asked if she had any questions. Sarah seemed confused. She seemed not to know what she was supposed to say. She shook her head and said she had no questions.

I noticed a little card in front of her and asked what it was. She showed it to me. In a neat, feminine script she had written the word “hemipelvectomy.” I remembered her asking me earlier in the day what the name of her operation was and I noticed her copying it down.

“It’s not in the dictionary,” she said. “I looked.”

No, I didn’t suppose it would be.

“Can you tell me again what it means?”

I wasn’t sure how to explain it to her. It had been easier to hide behind the technical terminology. It was easier to obscure the truth than to illuminate it.

I tried to act casual, as though I were asked about hemipelvectomies all the time. “Hemi,” I began, “is from the Greek. It means half. Ectomy means to remove something. So hemipelvectomy means to remove half the pelvis.”

Sarah frowned in confusion. “But I thought you were going to remove…my leg.”

“Well, we are, Sarah. Your pelvis and your leg.”

“Oh.”

We were silent for a few moments.

“Will it hurt much?” she asked.

“You won’t feel a thing during the operation since you’ll be asleep.” I spoke with the casual ease of an experienced surgeon. “But most patients do have some pain afterward.”

Shut up, you asshole, I screamed at myself. You’ve never even seen a hemipelvectomy.

I just stood there, squeezing her chart until I couldn’t stand it any longer. I turned and started to walk away, then turned back. “Sarah,” I said finally, “I…Well, I’ll do everything I can for you.”

She looked at me and smiled kindly. Now it was she who was providing the care. She was a mother comforting her little boy. She reached out, touched my forearm, and said simply, “I know you will. Thank you.” She was so confident, so trusting. This was the Mayo Clinic. We would save her.

I wondered later who was more naive, Sarah or me. But, of course, it was no sin for Sarah to be naive…

 

Sarah was the first case, so the orderly came for her at 6:00 A.M. Her parents followed behind. I was waiting for them when they arrived at the surgical holding area. At the door the orderly stopped so Sarah could kiss her parents good-bye. Her father leaned forward and kissed Sarah on the cheek. He squeezed her shoulder, then quickly turned away, hiding his face from her. Her mother stepped forward, her eyes filled with tears. Sarah struggled to sit up. They tried to embrace, but the IV kept getting in the way.

“I love you, Sarah,” her mother said.

“I love you, too, Mom.”

They continued to reach for each other as the orderly pushed Sarah through the double doors into the brightly lit holding area. Sarah’s mom kept her arm extended toward her daughter as the doors swung shut with a gasp of compressed air.

I helped the orderly wheel Sarah into the corner where I introduced her to another orderly, Luella, who was going to do the prep. While the pre-op nurse was attaching a bag of antibiotic solution to the IV, Luella explained that she was going to scrub and shave Sarah’s leg. I sat at the desk as Luella swung the curtains around Sarah’s cart.

I could hear Luella tear open the surgical scrub sponge and begin the prep. “I even have to get up around your private area, honey,” Luella said. “Can you raise your bottom a little?” I could see the shadow on the curtain as Luella had Sarah bend her knees and spread her legs. Every bit of her pubic hair had to be shaved away.

Five minutes later Luella asked Sarah if she had ever had a catheter.

“No,” Sarah replied in a barely audible voice.

“The catheter goes into your bladder,” Luella told her. “That way whenever you need to pee it will just come out through the tube.”

Sarah was told to spread her legs again. Luella washed her with a warm, soapy solution, then painted her with betadine.

“This might hurt a little,” Luella said.

Sarah gave a brief gasp.

“There, now,” Luella said. “All done. Let me get a blanket from the warmer.” Luella was back in a few seconds. She tucked a warm blanket under Sarah’s chin, then tore back the curtain. “Bye, honey,” she said, patting Sarah on the shoulder. “Anything else I could get for you?”

“No,” Sarah whispered.

An anesthesiologist came in and talked to her about the procedure. He said once she was asleep he was going to put a breathing tube in her mouth. He also said she might be given some blood during the surgery. He asked if she had any questions.

Sarah, who seemed not to have heard a thing he said, answered, “No.”

She lay quietly, watching the nurses scurrying back and forth between patients, starting IVs, hanging antibiotics, taking blood pressures and temperatures.

Finally I went over to her. “Sarah, have you had anything to eat or drink since midnight?” I asked.

She shook her head. “No,” she said.

“Okay then, Sarah, it’s time to go.”

I unlocked the cart and swung it out from the stall. We passed through a series of double doors before finally entering the OR. As always, it was cold, and intensely lit. As we entered, I pulled up the mask that had been hanging below my chin. I docked the cart next to the narrow, black operating table and asked her to “scoot over.” The circulating nurse whisked Sarah’s blanket away and Sarah gasped at the cold. As she started to move to the OR table her gown rode up to the top of her thigh. Sarah had been told not to wear panties and she blushed as she tried to tug her gown back down. One of the nurses helped her, then covered her with a warm blanket.

Two arm boards were swung out from the side of the table and Sarah lay with her arms extended to either side. The anesthesiologist wrapped a blood pressure cuff around her right arm while one of the nurses adjusted the IV in her left. Another nurse returned with two more blankets from the warmer. Sarah tried to shrink beneath them.

Just as she was starting to warm up, the anesthesiologist pulled the blankets away and calmly mentioned he had to “place some leads.” Sarah blushed again as he reached under her gown and placed several cold, sticky patches above and below her breasts. As soon as he replaced the blanket another nurse said in a cheerful voice, “Cold, sticky pad!” She slapped a large, cold pad on Sarah’s right thigh. A clear electrical wire ran from the pad to a machine next to the table. “That’s your grounding pad,” the nurse said. Sarah smiled and nodded as if she knew what a grounding pad was.

I could see Sarah’s eyes begin to glaze over. “I have just given you a little something in your IV to relax you,” the anesthesiologist said. I stood next to her, leaned over. “Are you cold, Sarah?” I asked as I tucked the warm blanket under her chin.

“Please,” she said, her voice raspy and small. Her eyes welled up with tears. She struggled to sit up. “Please don’t…”

As the anesthesia began to take effect she sank back down and closed her eyes. “Don’t worry, Sarah,” I said. “We’ll take good care of you.”

The anesthesiologist told Sarah to take a couple big, deep breaths…

 

From start to finish it was a horrible operation. Oh, nothing went wrong from a technical sense, but the whole thing was so wrong, so unfair. For the first time I began to wonder if we were part of Sarah’s problem rather than part of her salvation. Even the prep and drape seemed obscene. We turned Sarah on her right side, and prepped her from the low back to the knee. We then covered everything except her left leg with sterile drapes. Sarah had now disappeared, buried under a mound of blue drapes. We were no longer operating on a person. We were operating on a tumorous appendage emerging from a blue hole.

Bill took the sterile marking pen and outlined his incision. I held Sarah’s leg high in the air and watched in awe as the purple line skirted her labia, swung up almost to the lower abdomen and then dipped back and around the upper buttock. When he had finished he dropped the marking pen on the Mayo stand and held out his hand.

“Scalpel.”

It was a long, bloody operation. I was constantly clamping and cauterizing and placing retractors, trying to give Bill the best exposure. As the operation progressed, Bill and the anesthesiologist conversed frequently, deciding when to give the next unit of blood or fresh frozen plasma. There was a steady flow of blood products going in her arm and oozing out her surgical wound.

Every move we made caused more bleeding. Blood pumped and oozed and leaked and squirted. We soon became oblivious to it. Our gloves became tacky and thick with it. Blood spread up our sleeves and coated the front of our gowns. Blood seeped into the surgical sheets and spread down the side of the drapes. Blood dripped on our shoes and soaked into the blankets the nurses had cast on the floor in front of us.

Slowly, over several hours we began to separate Sarah’s long, shapely leg from the rest of her body. The two edges of the incision grew farther and farther apart. When we finally severed the iliac bone, the leg dangled obscenely from a few posterior tendons. These Bill quickly severed and the leg was free.

I lifted the leg, the gaping wound at the top still oozing blood, and slid it into a sterile, plastic bag the circulating nurse held for me. As the leg dropped into the bag the nurse couldn’t hold it and it fell to the floor. One of the other nurses came forward and helped wrap the leg. I glanced briefly over my shoulder as the circulator, carrying her burden in front of her, exited the room and headed to Surgical Path.

Bill and I still had another couple hours of work to do. There was a question of how many sacral nerves we could spare. If we took too few, we would increase the chance of tumor recurrence. If we took too many, Sarah’s bladder and perhaps her and sphincter wouldn’t work.

I stared into her huge open wound and saw virtually nothing familiar. It was all virgin territory to me. I had assisted on plenty of hip operations, but had never seen the inside of the pelvis like this.

That must be the vaginal wall over there, I thought. And up there, the side of the bladder; behind the bladder, a portion of the rectum and the sacral plexus. And dangling everywhere were the tangled shreds of nerves, vessels, and tendons.

Closure seemed to take forever. There were several layers of tissue that had to be approximated. Then we had to decide how best to close the skin. Should we trim here? Advance there? Tuck this? Excise that?

By the time we placed the last drain and put in the last suture, it was early afternoon. Sarah’s pressure was stable. She had been given eighteen units of blood but had come through the procedure well.

Bill went to talk to the family, and left me to apply the dressings. I peeled away the bloodstained sheets. For a brief moment, after the drapes had been removed and before the nurses had been able to cover her with a fresh gown, Sarah lay totally exposed.

We tried not to stare. All of us—myself, the anesthesiologists, the nurses—quickly found other things for our eyes to do. But the truth was there now, the truth we had tried to hide under all those layers of sterile, blue surgical drapes. Sarah had no leg. There was a long line of black sutures across the left side of her lower abdomen, and below that—nothing.

I applied the dressings, being careful not to disturb the catheter. Sarah’s skin was pale and cold. I lifted the drain reservoirs onto her belly, then we moved her off the operating table and back onto the cart. It wasn’t difficult; she didn’t weigh much anymore. The nurses covered her with warm blankets, and then I wheeled her to the recovery room.

Sarah’s post-op course was stormy. She ran a fever for four days. The inferior portion of her wound dehisced. Her labia swelled so much she couldn’t urinate. I tried to put a catheter back in her, but she was so swollen I couldn’t find the urethra. Finally we had to call a urologist to do it.

But Sarah was a marvel. She kept thanking us for all we were doing, and apologizing “for being such a bother.” She was as bright and engaging as ever. I couldn’t understand it. I thought if I lost my leg I would be inconsolable. I would never laugh again. Like Job’s wife’s I would want to curse God and die.

I longed to ask Sarah about it, but I didn’t know how. What would I say, “Sarah, shouldn’t you be more upset about having your leg chopped off?” Finally I approached Annie Cheevers, Sarah’s nurse. Annie had become like Sarah’s big sister.

“Sure, we talk about it,” Annie told me. “And of course she’s sad about losing her leg, but she says it’s made her realize how many things she hasn’t lost. She says it’s like a millionaire who loses a thousand dollars—he’s sad, but he’s still not that bad off.”

I thanked Annie and nodded thoughtfully, as though I understood, but I still didn’t get it. I was still too ignorant about what a scalpel could, and could not, do. All I could see was that we had taken away her leg. I didn’t yet understand that there are some things no surgeon, no disease, can ever take away.

Annie and the other nurses adored Sarah. The day nurse would come back at night to sit and watch TV with her. The night nurse would stay in the morning to have breakfast with her. The PM shift nurse would call as soon as she got home to be sure she was given her midnight meds. And how they guarded her. Every order, every procedure, was scrutinized.

“Dr. Collins, she just had her hemoglobin checked yesterday. Can’t we wait until tomorrow to check it again?”

“Dr. Collins, I noticed a little serous drainage coming from the bottom of her incision.”

“Dr. Collins, don’t go in now. She just fell asleep. Couldn’t you come back later?”

How thrilled we were three days after surgery when Sarah stood and took a few tentative steps on her crutches. She was pale and trembling as she looked at us for encouragement.

And how shocked I was seven days after surgery when I knocked on her door and heard Annie Cheever’s voice tell me to “wait just a minute.” I stood at the door, looking at the curtain that had been drawn around the bed, thinking Sarah must be on the bedpan. But why the bedpan? She had been walking to the bathroom for several days now. Finally Annie pulled back the curtain, gestured dramatically at Sarah, and said, “Ta-da!”

Sarah was sitting on the edge of the bed smiling at me. Annie had helped her wash and set her hair and apply her makeup. She was stunning. I stared at her, a myriad of emotions swirling inside me.

Annie began to laugh. “I think he likes it, Sarah.”

“Sarah,” I said, “you look…nice.” It was my turn to blush.

Annie was outraged. “Nice? That’s all you can say? That she looks nice?”

“I, uh, well you look really nice. I mean—”

They both laughed. They knew they had succeeded.

Sarah went home a few days later. She gave me a big hug and thanked me for saving her. I looked away and said nothing. I saw her two weeks later when she returned to Rochester for a post-op visit. After that I moved to another service. But for months afterward I would see the black suture line running across the stump of Sarah’s left pelvis; and I would wonder just what it was Sarah thought she hadn’t lost.

But I was busy with other things, other patients, and soon I stopped thinking of Sarah at all.