Chapter 17

Wednesday, July 3, 1:22 p.m.

Mitt stood at the stainless-steel scrub sink outside of OR #4. He was in the process of using a disposable, blue plastic nail file to clean the subungual area of each finger. Dr. Kevin Singleton was to his right. To his left was Dr. Taylor Smith, Bellevue’s chief of Head and Neck Surgery. All three men were scrubbing for the upcoming thyroidectomy on Diego Ortiz. Mitt was attempting to concentrate on what he was doing to proactively avoid thoughts about Elena Aguilar in the PACU and his possible role in her seemingly downhill clinical course. He specifically didn’t want to wonder how her electrolytes could have gotten so screwed up.

Kevin had introduced Mitt to Dr. Smith out in the surgical lounge but the introduction had been cursory, as Dr. Smith had simultaneously become preoccupied by an incoming call on his mobile.

To Mitt’s eye, Dr. Taylor Smith was a man of indeterminate genealogy, probably in his early fifties. He was darkly complected, rather hirsute, and slender with a scraggly, graying goatee and mustache, which Mitt thought might be to compensate for scant hair on his head. Mitt mused that he’d rarely come across Taylor as a male given name although he knew several women, including the popular singer. As these arbitrary mental gymnastics about Dr. Smith passed through his mind, Mitt recognized it was merely an attempt to keep from thinking about Elena Aguilar.

“Dr. Smith,” Kevin called, interrupting Mitt’s thoughts. “When I introduced Dr. Fuller out in the surgical lounge, I didn’t get a chance to tell you that he is one of our brand-new NYU surgical residents.”

“You don’t say?” Dr. Smith questioned with a slight English accent that confused Mitt even more. “Welcome, young man. How are you finding it so far?”

“Challenging,” Mitt responded, which certainly was the case.

“Well, then, we’ll have to make this interesting for you,” Dr. Smith added. “I was wondering why I was getting two assistants, and a fourth-year resident at that. How much do you know about thyroid surgery?”

“I know approximately where the thyroid gland is located,” Mitt said.

“Ha, ha, I like your sense of humor!” Dr. Smith responded. “To start off, do you know why this is being handled as an inpatient rather than an outpatient procedure, which is the way I’ve been doing most of my thyroidectomies these days?”

“I’m not sure,” Mitt said.

“The patient has a history of severe hypothyroidism requiring thyroxine replacement. Post-surgery, he’ll need to be covered intravenously for a short time until he can take it orally. It is safer as an inpatient.”

“That makes sense,” Mitt said. He remembered the patient’s history from doing the admission workup.

When the three had finished scrubbing, they entered the OR in descending order of status. Once inside, Dr. Smith introduced Mitt to the two nurses, Marianna, the scrub nurse, and Juana, the circulating nurse. During the gowning-and-gloving routine, the same order was followed with Dr. Smith first, Dr. Singleton second, and Mitt last. During the process Dr. Smith maintained an explanation of what had already been done to facilitate the surgery, namely that the patient had been intubated with a special endotracheal tube that incorporated a monitoring device to protect the function of the recurrent laryngeal nerve. He went on to explain that damage to that particular nerve was one of the complications of the surgery and needed to be scrupulously avoided by continuously monitoring the nerve’s function. Additionally, at his request the patient had been positioned with his head nestled in a donut to maintain its position and a roll had been placed under the patient’s shoulders to hyperextend the neck, all to facilitate the surgery. Dr. Smith gave credit to the anesthesiologist and Juana for carrying out all these preparations.

Mitt was impressed by Dr. Smith’s pedagogical inclinations and was now genuinely interested in the upcoming procedure. He believed it might turn out to be the best teaching experience he’d had so far in the operating room. At the moment he wasn’t even feeling tired, and more important, he wasn’t obsessing about Elena.

“Which side do you want to be on?” Dr. Smith asked Mitt after the patient had been draped, and Marianna, the scrub nurse, moved the instrument tray over the patient’s legs to be close enough to hand the surgeon what he needed. When Mitt glanced at the instrument tray, he couldn’t help but notice there was a fairly large instrument he didn’t recognize that looked like it belonged in a plumber’s toolbox. It seemed that there were lots of new aspects to the case. Earlier Dr. Smith had used a marking pencil to indicate where he would be making the incision while explaining to Mitt that careful planning of the exact location of the incision would improve the cosmetic result, hiding the scar within a neck fold.

Straining under a bit of informational overload, Mitt struggled to answer which side of the operating table he wanted to be on, as he’d not been asked before. “I don’t know if I have a preference,” he said ultimately, shrugging his shoulders. “What side do you think I should be on?”

“I don’t have a preference, either,” Dr. Smith said. “I’ll be using a small five- or six-centimeter incision, as you can see by my marker. I want you to be where you will see as much as possible.”

“I think he should be over here,” Kevin said, speaking up. He was already standing on the other side.

“Fine by me,” Dr. Smith said agreeably. He gestured for Mitt to head over there by rounding the foot of the operating table.

Mitt quickly did as he was told and ended up in his usual location between the first assistant, Kevin, and the anesthesia screen. Encouraged by Dr. Smith’s general attitude, Mitt asked about the strange instrument on the tray, which looked like a cordless soldering gun.

“That’s a harmonic scalpel,” Dr. Smith said with a chuckle. He picked up the instrument and held it closer to Mitt so he could appreciate it close up. “It’s a marvelous piece of technology that cuts and cauterizes at the same time using ultrasonic energy. The thyroid is a heavily vascularized gland, and hemostasis is of particular importance. I like the harmonic scalpel particularly because it has minimal thermal spread, so it can be used near critical tissues, like the recurrent laryngeal nerve and the lower parathyroid glands, when we have to dissect out the inferior thyroid artery.”

“Interesting,” Mitt said, and meant it. He was wracking his brain at the moment to remember anatomical details about the thyroid gland from his first-year medical school cadaver. He wished he’d reviewed the details the night before with one of the anatomy books he had in his apartment, but then he remembered how tired he’d been.

“Okay,” Dr. Smith said. He looked over the anesthesia screen at the anesthesiologist. “Everything ready? Is the nerve monitor functioning okay?”

“Everything is ready,” the anesthesiologist said.

“Regular scalpel, please, Marianna.”

Marianna slapped the scalpel into Dr. Smith’s waiting hand. Using it, he made an incision down through the skin, subcutaneous tissue, and the superficial muscle layer along the line he’d made with the marking pen. “Do you know what this muscle is called?” he asked Mitt as he quickly worked.

“Platysma?” Mitt was nearly certain of the name but still posed it as a question for the usual reasons.

“Right you are,” Dr. Smith said. “Now, as you can see, I’m going to create skin flaps deep to the platysma but superficial to the sternohyoid and sternothyroid muscles, being very careful to avoid the anterior jugular vein as well as the superficial veins that lie under the platysma.” He continued to seemingly revel in the teaching.

Mitt didn’t respond audibly but nodded several times as he watched Dr. Smith carefully undermine the skin flaps on either side of the neck. When the flaps were done, the surgeon then used the scalpel to cut vertically through what he called the median raphe between the two major neck muscles. It was at that point that Mitt was handed several retractors. These were tiny compared to the retractors he’d been using during all his previous surgeries. With them in place he could see everything clearly, especially as Dr. Smith continued to point out all the appropriate landmarks while using the harmonic scalpel to expose the thyroid gland, first its left lobe and then its right. Mitt even got to see the pulsating carotid sheaths on both sides. The most critical parts of the procedure were the isolation of the major arteries and veins, particularly from the nerves and inferior parathyroid glands, and then their ligation and severance, all of which was described in detail to Mitt and performed right under his nose. All in all, as the surgery progressed, it became the most engaging anatomy lesson he’d ever had, and for the first time in three days Mitt was totally absorbed, finally feeling that being a first-year surgical resident wasn’t all bad.

“Okay, Juana,” Dr. Smith said, getting the circulating nurse’s attention. She’d been reading a paperback book while sitting on a stool in the corner. “We’re going to want frozen sections on these lymph nodes just to be a hundred percent certain they are cancer free.” He had dissected them from beneath the left lobe of the thyroid gland directly under the location of the small cancer nodule. He then handed them off to Marianna, and Marianna, in turn, put them in a sample container, which she dropped into Juana’s waiting hand.

“I’ll be right back,” Juana announced before disappearing out through the operating room door into the hall. She could have called down to the front desk to have someone come by to get the sample, but it was much quicker to do it herself. Surgical Pathology was just a few doors down the hallway.

At the same time Juana was on her short mission and the anesthesiologist was busy manually checking the patient’s blood pressure, Dr. Smith and Dr. Singleton became engaged in a mini debate over a particularly esoteric operative detail. Momentarily on his own, Mitt straightened up from having been slightly bent over to get the best view possible through the tiny incision. As he lifted his shoulders and stretched his neck muscles, he raised his eyes toward Dr. Smith, who was wearing a pair of magnifying optical loops. But then over the surgeon’s shoulder, Mitt’s attention was drawn to the door near the circulating nurse’s built-in desk, which connected to the sterilizer room, as it began to open.

At first the door’s opening hardly registered in Mitt’s brain since he naturally assumed it was Juana returning on an alternate route from her short errand. Besides, his mind was still totally occupied in marveling at how interesting Dr. Smith had made the thyroidectomy case. But then to his shock, he was jolted to see the person who threatened to enter wasn’t Juana, but rather the blond girl in the bloodstained dress. She had the same pencil-like stainless-steel instrument in her hand that she’d had before and she was again pointing it at him, either to show it to him or threaten him, he didn’t know. And as an added horror, she wasn’t alone. Pushing against her back, seemingly trying to break out of imprisonment in the sterilizer room, was a silent but angry band of hideously injured people in all manner of period dress and undress, some carrying their severed and bloody limbs or intestines. Intuitively Mitt knew that all of them had been operated on at Bellevue Hospital in the distant past.

“Oh my God! No!” Mitt gasped under his breath.