It’s 5 o’clock, and the long cases are over. There’s just one more to go—the last of the day. One of my partners throws open the operating-room door and stands facing me with his mask down around his neck, his surgeon s gown backward and hanging open over dirty scrubs, his pants pulled low by double pagers at his waist.
“Want me to do your last case?” he asks.
I consider saying yes—my shoulders ache. I’m getting a cold, and I’ve been here since 6:30 a.m. “Nah, but thanks.” I know the case will be short. Better to save up favors for when the kids are sick or have a basketball game.
Anyway it’s a simple case. Pretty straightforward. Not even a general anesthetic but intravenous sedation for a central line insertion, probably for chemo or something. Young patient—a young woman—a surgeon I like, nurses I enjoy working with. Easy as can be, no more than an hour. I draw up drugs into fresh syringes. The surgeon will inject local anesthetic into her skin. I pick up the phone in the OR, call home and tell my older daughter I won’t be too late tonight. She says she needs help with math homework.
In presurgery, where the patients wait with family members, I flip open my patient’s chart to the nursing admission form. The patient’s name is Onica M.; the diagnosis is breast cancer, recurrent. The hospital stamps her identification card on the right-hand corner of each page of her chart. The stamp shows her age as 039. This distinguishes her from patients named Onica M. with recurrent breast cancer who are, perhaps, 139? I, too, am 039.
Onica lies on a metal cart, dressed in the universal uniform of the patient—the hospital gown that snaps at the shoulders and ties in the back. She’s covered by the usual institutional white sheet, over which the institutional white blanket has been placed to prevent the institutional chill. She’s been stripped of her clothes, jewelry, nail polish and makeup; her distinguishing characteristics are now elemental—she’s allowed to maintain her general build, hair color, facial features. Soon we’ll cover her head with a disposable hat, and she’ll look almost like us—except of course for the ways in which terminal disease has transformed her. That’s always the giveaway.
When I reach out to shake her hand, I notice she’s tiny, thin, petite—a sprite of a person. Big-boned and tall, more like my father than my mother, I’ve always envied petite women, the way they constantly surprise you by being more than they seem. During adolescence I stared at my thighs and longed to be shorter, as short as most other girls, short enough to be normal. Now I no longer mind the height, but I still take note of what I’ll never be.
Onica’s skin is light tan and her hair light brown. She reaches out to grasp my hand with her small, bony one, holds it fiercely in hers, grips mine a moment longer than necessary. Her hand makes me think of a crunchy, Middle Eastern delicacy: the fig birds they deep-fry and eat whole. When she releases me, her arm remains outstretched, suspended, floating in space, as if she isn’t sure she should have let go. We smile at each other, or rather, I do; she doesn’t smile so much as grin. Onica is cute, a pixie, a pert, perky woman who might have been a member of the pompon squad in high school, like Annette Sullivan or Sherry Kopinsky. Someone everyone liked. Dimples crease her cheeks when she grins. I shake hands with her father, who sits quietly beside her, staring at nothing, looking prosperous but lost, ineffably sad.
He kisses Onica’s cheek, then we leave him in presurgery and wheel Onica back to the operating room, where I attach the monitors—ECG electrodes, blood-pressure cuff, pulse oximeter. I start giving her drugs. Lidocaine, then fentanyl, then midazolam. I plug in the propofol infusion, set the pump to her body weight and a low dose. I can judge the effects of the medication more easily if she’s talking, so while the drugs are starting to work, I ask her questions. I pay attention to the pace and cadence of her answers, wait for the speech to gradually slur. Everyone’s tolerance is different, so I titrate the drugs to the desired effect.
“Are you married?” I ask, holding her arm above the IV site, rubbing gently to take the sting out of the medicine.
“Oh, yeah,” she answers, her voice bright with enthusiasm, “and I’ve got two kids, a boy and a girl.”
“How old are they?”
“My son is 11, and my daughters 9.”
“So they’re what—in third and fifth?”
“Third and sixth,” she answers, her words slightly thick, coming a little bit slower. “They’re two and a half years apart, but three years in school.” I look down and smile behind my facemask. Once again I see that grin—a quick twitch of tense facial muscles. Onica uses her dimples wisely, I think. She uses them to hide her fear, perhaps, or anger or sadness. In truth I don’t know what she hides. I can’t even imagine, so I slide another milligram of midazolam into her IV.
“What sports do they play?”
“Douglas, my son, well, Douglas… likes… soccer…” Her eyes drift shut, and I nod to Maylie, the circulating nurse. She can begin the prep.
Maylie brings the prep stand close to the OR table. She folds the cotton blanket down to Onica’s waist, refastens the safety belt on top of it. She removes the hospital gown, unsnapping it at the shoulders and turning it down to the waist. Despite the noise of the monitors, I hear Maylie’s gasp. On Onica’s chest, in place of breasts, which I knew she didn’t have, sit two raw, lumpy, ulcerative masses. Scarred, puckered, with purple draining from angry red, these things disfigure her small body and silently scream cancer. I turn away, pull down my mask, and take a deep breath. Mercifully, amazingly, there is no odor. After a moment I look back and meet Maylie’s tired eyes. Our gazes are drawn back against our wills to Onica.
“What…?” Our scrub nurse, Paula, stops speaking, looks at me.
I shake my head. Though her eyes are closed, our patient is technically awake.
Gish, the general surgeon, enters the OR with hands raised and dripping. Paula hands him a towel, and as he dries his hands, he walks toward me and leans close.
“She had a TRAM flap breast reconstruction elsewhere,” he whispers, “then a recurrence of her cancer. She got irradiated, and the flap broke down. That’s all scar tissue and cancer.” He backs away and looks straight at me. “Nice, huh?”
I sit down at the head of the OR table, touch Onica on the shoulder. “How you doing?” I ask. “You okay?”
She murmurs an assent, and once again, a slight grin appears and disappears. Her eyes remain shut. I stand up to affix the drapes, give Onica an additional bolus of propofol before Gish injects the local anesthetic into her skin. I whisper, “You’ll feel a little sting now, as the numbing medicine goes in.”
She barely flinches with the needle stick. I sit back down to continue my charting, observing Onica frequently to make sure she stays sleepy and unaware throughout the procedure. I listen to the rhythmic pattern of the monitors, the buzz of the electrocautery unit, while another part of me hurtles through space, through time, forward blindly, without any understanding of how movement occurs, entangled in the flawed harness of the helping profession. Though there are many layers to this job, the horror is a small part, a part that can be ignored, if you know how, that is, if you’re good at it. I am a professional trained to function within an official, circumscribed vocabulary. The words I need—right now—to describe this exact moment don’t exist within that lexicon.
Here’s the thing. I absorb horror only in snippets, in quotas, one at a time, day after day. I preserve their essences, tell myself I will attend to them later, after the homework—perhaps I even mean it— but then another patient comes along. There’s another job to do, another mess to slog through, and fatigue sets in; life sets in, and I don’t do it. Not right, anyway. Not well enough. Part of this is self-protection. The other part, I’ve come to understand, is that compassion ultimately fails. How else can it be? I take care of patients when I am tired and alert and proud of my children and angry with my husband and upset because the radiator pipe broke and flooded my kitchen and when I am worried about the dog’s rash. I have, after all, a job to do. I cannot permit immobilization. But on certain days with certain patients—she is 039, like me—I cannot help but see the whole of it.
I look back down at Onica, at the half-grin she wears even in repose. I remember the first TRAM flap I saw, and the anger comes rushing back to me. I’ve hated that plastic surgeon ever since. Does anger assuage survivor guilt? Perhaps my feelings are political, leftovers from a feminist upbringing. Who but a man would be clever enough to imagine transforming womanhood in the first place— relocating abdominal muscles upward to recreate breast tissue while performing a concomitant tummy tuck? Massive surgery, long hours of blood loss and anesthesia, undoubtedly sold on the premise that one surgery fixes you right up—good as new, better even. Then the cancer recurs—of course it does—in our patient, this young mother of two who will not see her children grow up but will watch them as they watch her suffer and die a slow death with little or no dignity.
In the recovery room, Onica is awake again and cheerful. I stand at her bedside and say nothing, just fiddle with the wires connecting her to the monitors. I ask mundane questions: what her husband does, where she grew up. I do not ask the questions I want to ask: Do you have a family history? What asshole plastic surgeon talked you into this abomination? How do you discuss the cancer with your kids? I do not ask, though I know she would tell me. It would be so easy to plunder her medical history. Onica M., with the grin for others, would tell me all her secrets, answer the questions I have no right to ask. But I don’t ask. Someday perhaps I’ll learn a language in which compassion does not fail or intrude or strip a sick woman of her strength or self-protection, a language in which compassion thrives, despite this gilded vocabulary. Maybe someday I will learn that language; I do not know it now.
My pager goes off yet again. Both daughters now need help with their math homework. Still I sit beside Onica until she leaves the recovery room to go back to her father, her family, her life and the end of her 39th year.