There was an audience in the O.R. today—two medical students from the university, and Lucy beckoned them closer. The scrub nurse passed a knife, and Lucy began to scrape the tip of the blade against the exposed flesh of the thigh, talking as she worked.
“You’ll notice that I’m marking the level of the flaps by scratching them on first. That’s to give us our landmarks.” Now she began to cut more deeply, exposing the fascia immediately below the skin, with its layer of yellow fatty tissue. “It’s important always to make the front flap longer than the back one, so that afterward the suture line comes a little posterially. In that way the patient won’t have a scar right at the end of the stump. If we did leave a scar in that position it could be extremely sore when any weight was put upon it.”
Now the flesh was cut deeply, the lines of both flaps defined by the blood which had begun to seep out. The effect, front and rear, was rather like two shirttails—one long, one short—which eventually would be brought together and sewn neatly at their edges.
Using a scalpel and working with short, sharp movements, Lucy began to strip back the flesh, upward, exposing the bloody red mass of underlying tissue.
“Rake, please!” The scrub nurse passed the instrument and Lucy positioned it, holding back the loose, cut flesh, clear of the next layer below. She signaled to the intern to hold the rake in place, which he did, and she applied herself to cutting deeper, through the first layer of quadriceps muscle.
“In a moment we shall expose the main arteries. Yes, here we are—first the femoral vessel.” As Lucy located it the two medical students leaned forward intently. She went on calmly, matching her action to the words. “We’ll try to free the vessels as high up as possible, then pull them down and tie off so that they retract well clear of the stump.” The needle which the scrub nurse had passed danced in and out. Lucy tied the big vessels twice to be sure they were secure and would remain so; any later hemorrhage in this area could be catastrophic for the patient. Then, holding her hand for scissors, she took them and severed the main artery leading to the lower limb. The first irrevocable step to amputation had now been taken.
The same procedure followed quickly for the other arteries and veins. Then, cutting again through muscle, Lucy reached and exposed the nerve running parallel downward. As her gloved hands ran over it exploringly, Vivian’s body stirred suddenly on the table and all eyes switched quickly to the anesthetist at its head. He nodded reassuringly. “The patient’s doing fine; no problems.” One of his hands was against Vivian’s cheek; it was pale, but her breathing was deep and regular. Her eyes were open but unseeing; with her head fully back, untilted to one side or the other, the pockets of her eyes were deep with water—her own tears, shed in unconsciousness.
“We follow the same procedure with the nerve, as with the arteries and veins—pull it down, tie it off as high as possible, then cut and allow it to retract.” Lucy was talking almost automatically, the words following her hands, the habit of teaching strong. She went on calmly, “There’s always been a lot of discussion among surgeons on the best way to treat nerve ends during amputation. The object, naturally, is to avoid pain afterward at the stump.” She deftly tied a knot and nodded to the intern, who snipped off the spare ends of suture. “Quite a few methods have been tried—injection of alcohol; burning the nerve end with an electric cautery; but the method we’re following today is still the simplest and most widely used.”
Lucy glanced up at the clock on the O.R. wall. It showed 9:15—forty-five minutes so far since they had begun. She returned her eyes by way of the anesthetist.
“Still all right?”
The anesthetist nodded. “Couldn’t be better, Lucy. She’s a real healthy girl.” Facetiously he asked, “You sure you’re taking the leg off the right patient?”
“I’m sure.”
Lucy had never enjoyed operating-room jokes about patients on the table, though she had known some surgeons who wisecracked their way from first incision to closure. She supposed it was all in your point of view. Perhaps with some people levity was a means to cover up deeper feelings, perhaps not. At any rate she preferred to change the subject. Beginning to cut the muscles at the back of the leg, she asked the anesthetist, “How’s your family?” Lucy paused to use a second rake to hold back the flesh from the new incision.
“They’re fine. We’re moving into a new house next week.”
“Oh, really. Whereabouts?” To the intern she said, “A little higher, please. Try to hold it back right out of the way.”
“Somerset Heights. It’s a new subdivision in the north end.”
The back leg muscles were almost severed. She said, “I think I’ve heard of it. I expect your wife is pleased.”
Now the bone was visible, the whole incision big, red, gaping. The anesthetist answered, “She’s in seventh heaven—buying rugs, choosing draperies, all the other things. There’s only one problem.”
Lucy’s fingers went around the leg bone, working up and freeing the surrounding muscles. Speaking for the students’ benefit, she said, “You’ll notice that I’m pushing the muscles as far out of the way as I can. Then we can sever the bone quite high so that afterward it will be entirely covered with muscle.”
The intern was having trouble holding back the overlapping muscles with his two rakes. She helped him position them and he gumbled, “Next time I do this I’ll bring my third hand.”
“Saw, please.”
Again the scrub nurse was ready, placing the handle of the bone saw in Lucy’s outstretched palm. To the anesthetist Lucy said, “What problem is that?”
Positioning the saw blade as high as she could, Lucy began to move it in short, even strokes. There was the dull, penetrating sound of bone scrunching as the saw teeth bit inward. The anesthetist said, “Paying for it all.”
Lucy laughed. “We’ll have to keep you busier—schedule more surgery.” She had sawed halfway through the bone now; it was proving tougher than some, but of course young bones were naturally hard. Suddenly the thought occurred to her: this is a moment of tragedy, and yet here we are, casually talking, even jesting, about commonplace things. In a second or two, no more, this leg would be severed and a young girl—little more than a child—would have lost, for always, a part of her life. Never again would she run freely, wholly like other people, or dance, or swim, or ride horseback, or, uninhibited, make love. Some of these things she would eventually do, and others with effort and mechanical aid; but nothing again could ever be quite the same—never so gay or free or careless as with the fullness of youth and the body whole. This was the nub of the tragedy: it had happened too soon.
Lucy paused. Her sensitive fingers told her that the saw cut was almost complete. Then, abruptly, there was a crunching sound, followed by a sharp crack; at the last moment, under the weight of the almost separated limb, the final fragment of bone had snapped. The limb was free and it fell to the table. For the first time raising her voice, Lucy said, “Catch it! Quickly!”
But the warning was too late. As the intern grabbed and missed, the leg slipped from the operating table and thudded to the floor.
“Leave it there!” Lucy spoke sharply as, forgetful of the fact that he would render himself unsterile, the intern bent to retrieve the limb. Embarrassed, he straightened up.
The circulating nurse moved in, collected the leg, and began to wrap it in gauze and paper. Later, along with more packages containing other surgical specimens, it would be collected by a messenger and taken to Pathology.
“Hold the stump clear of the table, please.” Lucy gestured to the intern, and he moved around her to comply. The scrub nurse had a rasp ready, and Lucy took it, feeling for the rough edges of bone that the break had left and applying the rasp to them. Again for the students she said, “Always remember to get the bone end clean, making sure that no little spikes stick out, because if they do, they’re likely to overgrow and become extremely painful.” Without looking up, she asked, “How are we doing for time?”