CHAPTER 5
Elena
◆
The locker room at six in the morning is the warmest room I have been in since I left the brownstone office last night, and that warmth is a fact I am noticing in my body before I am noticing it with words.
I touch each button on the cardigan I pulled over my street clothes on the way here.
Five. I mark them again. Five. I take the cardigan off and fold it into the locker on top of my coat.
I tie my hair into the knot at the nape and push the yellow pencil through it.
I straighten the pediatric pin on the lanyard.
I touch the medallion at my sternum once with the pad of my right index finger and tell Saint Raphael, very quietly, that I would like to be useful today.
The angel has a hairline crack across one wing.
The chain has been resoldered twice. The metal is cold for three beats and then warmer.
Beatriz Aguilar comes through the locker-room door with two coffees in a single tray and hands me one without asking what is in it.
"Mija," she says. "OR-4. Eight-hour case. Mikhailov's CABG. You circulate."
"Circulating."
"Circulating. I am scrubbing. Don't argue with me about it."
I take the coffee. I do not argue with her about it.
---
OR-4 at seven-thirty-six smells like every cardiothoracic room I have ever walked into and a little like Stefan, which is a thing I am letting myself notice once and then putting down.
The bypass machine sits in the corner like a furniture-sized animal that breathes when it is asked to.
The perfusion pump is set. The cooler box for the harvested vessel has been moved to the back wall.
The overhead surgical lamp is the OR-3 model, not the OR-4 one — somebody has swapped the heads for the week, somebody has told me about it, somebody is Beatriz and she told me yesterday.
The center bulb has a slightly yellowed cast. I note its arms. Three articulated.
The shadows it throws over the empty table are not yet four; they will be four when the team is in.
The patient is sixty-eight, three-vessel disease, ejection fraction at thirty-five.
The chart is open at the anesthesia cart.
I read it once, close it, set it back. I sign the count sheet.
I check the laps twice. I check the instruments — twenty-six on the mayo, eight on the back table — and I mark them again because Beatriz once told me that the first count is for the chart and the second is for the patient.
I scrub.
The scrub sink in the OR-4 anteroom is the new model from the renovation, a stainless deep basin with a knee-paddle and a wall-mounted chlorhexidine dispenser at my left elbow.
I take a brush. I open the gluconate packet.
The smell hits the back of my nose with the small medicinal sting it always has — iodine in the family of it, not iodine itself, the orange-amber soap that goes to a pink lather under water.
Three minutes per arm is the prescribed time and Beatriz has never let me cheat on it.
I lay the brush against my right forearm, knuckle to elbow, and start the count.
The bristles bite at the skin at the wrist where the bone is closest to the surface.
The burn there is faint at first and then specific, as a small careful pain becomes a slow-building loud one if you hold it long enough. The water is warm.
The lather is the color of melted apricot. I scrub through the count and the count is even and I keep my mind on the bristles, the lather, the warm water — not on the lab next door, not on the corridor downstairs, not on the man whose palm was at my sternum last night.
I let the count settle into my hands.
That is Stefan's count and I do not yet know I have learned it.
---
He comes in at seven-fifty-five. He stands at the second sink with his back to me for a moment before he turns.
The hunter-green of the cardiothoracic scrub is darker than the ceil-blue I am in.
His sandy hair is under the cap. The braided leather cord at his left wrist is just visible above the gluconate packet he is tearing open with his teeth.
"Doll. " He says it without looking at me. "If you would. Stand at his left. I want the count on the third graft in the left main. You will do that better than the resident I was given."
"Yes, Doctor."
"Stefan, if you would. In here."
"In here, Stefan."
His eyes come to me then. The hazel is gold-flecked because the over-bench fluorescent caught at the right angle. He smiles small, with the small smile of a surgeon about to put his hands inside someone else's chest and would like one piece of warmth to take in with him.
"Thank you," he says.
He scrubs. He has the brush moving in even strokes from the wrist to the elbow, three minutes by my watch and his, and on the third minute he turns his right hand palm-up under the water and I see it for the first time.
A vertical surgical scar down the center of his palm, four centimeters, raised and faintly pink, paler at the edges where the skin has had twenty years to forget the shape it was forced into.
The scar is on the inside of the palm where it should not be. The lather climbs over it and slides off and the scar is exactly where it was. He turns his hand back over and goes on counting.
I file it. The asking can wait. He will tell me when he tells me; that is the rule for the men on this floor, I have decided.
---
The CABG opens at eight-twenty-two. Stefan stands at the right side of the table.
The cardiac anesthesiologist takes the head; the perfusionist takes the pump; Beatriz scrubs across from him at the patient's left.
I float between the back table and the head of the bed.
Sternotomy. The saw. The smell of the small burn at bone.
The retractor. The pericardium tented and opened with the fine scissors.
The heart underneath, beating its own steady three-vessel insufficiency, the right coronary lazy at its bend.
I check instruments because I cannot count the next eight hours and I would like to count something. The mayo is full. The back table is full. The laps are at twelve. The number is exact.
Stefan asks for the vessel and the scrub gives him the segment from the patient's left internal mammary, then the saphenous from the leg.
He holds the mammary at the bench for a moment with both palms open like a man being given something fragile.
The cord at his left wrist sits against the cuff of the gown.
"Pump on."
"Pump on."
"Cross-clamp."
"Cross-clamp."
The aorta is clamped. The heart goes still under the lamp.
The shadows on the table fall in their full four — Stefan, Beatriz, the resident, the anesthesiologist's hand on the cardioplegia line — and the room takes on the particular small silence that cardiothoracic rooms take on when the heart is no longer beating and the machine in the corner has agreed to be the thing that beats instead.
I have stood in this silence twice before.
The first time I was twenty-one and I cried into my mask at the second graft. The second time was nine months ago. My eyes stay dry behind the mask. I take inventory.
Stefan counts too. He says it out loud at the third graft, low, conversational, under his breath, almost like welding music.
"One. Two. Three. Four."
He sets the suture. He sets the next.
"One. Two. Three. Four."
He is counting the rhythm of his own hands and he is counting the rhythm of the heart that is not there.
The fourth beat is the one he is listening for.
The fourth beat tells you whether the count will continue.
He has not told me that yet. I know it because I am standing two feet from him and I am counting with him under my breath.
My count is even. His count is even. We are counting the same four and my eyes stay on the field.
What is happening in my body stays unnamed. What is happening on the table I name aloud, in counts and instruments.
The third graft goes in. The fourth goes in.
Stefan asks for cold cardioplegia again at the eighty-minute mark and the perfusionist gives it to him.
The heart sits, blue-pale and obedient. Stefan's hands move without showing the work of moving.
The cord at his left wrist sits hidden under the gown — there all the same, I know it.
The fourth distal goes in at one-oh-six in the afternoon.
"Off cross-clamp," Stefan says.
"Off cross-clamp."
The clamp comes off the aorta. Blood goes back into the coronary tree under pressure. The heart sits still for six beats. Six is a long six. I track it in my own pulse against the back of my left thumb where I am holding a lap pad I do not need to be holding. Six. Seven. Eight.
The heart twitches at nine.
It catches at eleven.
It beats at thirteen, weak, then twenty seconds later in rhythm, then strong.
The relief that goes through me is the relief I have not been allowed to feel in nine months.
The heart on the table resumed and Sophia's heart did not.
The thought is small and it passes through me clean and it does not stay.
I take a breath through the mask. The cardiac anesthesiologist nods at the monitor.
Beatriz says nothing. Stefan says nothing.
Stefan's eyes go to the monitor and back to the field and his hands do not stop moving.
He looks up at the eight-minute mark, past the lamp, past the field, past Beatriz, and he finds me at the back table. He looks for half a second. He nods once. He goes back to the chest.
Whatever he saw, whatever he was looking for — he found it. I know that much. And I would like, very much, to be the kind of woman who is looked for and found in a room like this one.
---
He comes off the field at two-eleven. The chest is closed. The drains are in. The patient goes to the cardiac ICU at two-twenty-five with stable vitals and a blood pressure that pleases the perfusionist. Food, a chair, the noticing of either — all three have passed me by.